Creating a web-based incident analysis and communication system.

Area of Science:

• Patient safety
• Healthcare quality improvement
• Health informatics

Background:

• Hospitals conduct root cause analyses (RCA) for sentinel events (SE) to prevent adverse events.
• Limited dissemination of RCA action plans due to lack of standardized definitions and frameworks.
• World Health Organization's International Classification for Patient Safety (ICPS) offers proposed universal definitions and classifications.

Purpose of the Study:

• To develop a decision support tool for SE reviews aligned with the ICPS framework.
• To capture SEs and action plans in a searchable database for aggregate reporting.
• To facilitate standardized RCA and dissemination of action plans between hospitals.

Main Methods:

• Development of an intranet-based decision support tool.
• Integration with a secure, encrypted database for storing SEs and action plans.
• Inclusion of standardized input tools (drop-down lists, help functions) and RCA resources.
• Implementation of query functions for database searches and standardized reporting.

Main Results:

• Initial entry of 15 SE reports identified gaps in previous review processes.
• Positive assessments from safety personnel and health system leadership.
• Approval of funding for system-wide implementation evaluation.

Conclusions:

• The developed tool can be expanded beyond SEs to include all safety incidents.
• Demonstrates migration of ICPS classifications into a practical decision support tool.
• Potential to standardize RCA, disseminate action plans, and enhance overall patient safety.