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A review of medical error reporting system design considerations and a proposed cross-level systems research
Richard J Holden1, Ben-Tzion Karsh
1Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 1513 University Ave., Room 387, Madison, WI 53706, USA.
Objective:
To review the literature on medical error reporting systems, identify gaps in the literature, and present an integrative cross-level systems model of reporting to address the gaps and to serve as a framework for understanding and guiding reporting system design and research.
Background:
Medical errors are thought to be a leading cause of death among adults in the United States. However, no review exists summarizing what is known about the barriers and facilitators for successful reporting systems, and no integrated model exists to guide further research into and development of medical error reporting systems.
Method:
Relevant literature was identified using online databases; references in relevant articles were searched for additional relevant articles.
Results:
The literature review identified components of medical error reporting systems, error reporting system design choices, barriers and incentives for reporting, and suggestions for successful reporting system design. Little theory was found to guide the published research. An integrative cross-level model of medical error reporting system design was developed and is proposed as a framework for understanding the medical error reporting literature, addressing existing limitations, and guiding future design and research.
Conclusion:
The medical error reporting research provides some guidance for designing and implementing successful reporting systems. The proposed cross-level systems model provides a way to understand this existing research. However, additional research is needed on reporting and related safety actions. The proposed model provides a framework for such future research.
Application:
This work can be used to guide the design, implementation, and study of medical error reporting systems.
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