Information gaps in reporting patient falls: the challenges and technical solutions

Area of Science:

• Healthcare Informatics
• Patient Safety
• Human-Computer Interaction

Background:

• Medical error reporting systems are crucial for patient safety but often have fragmented workflows.
• The reporting stage is frequently disconnected from pre-event prediction and post-event solution stages, leading to information gaps.
• This disconnect hinders effective risk assessment, cause analysis, and user engagement in patient safety event reporting.

Purpose of the Study:

• To propose a model that bridges the information gaps in patient safety event reporting.
• To enhance user-centered design in computerized reporting systems.
• To improve the quality of reporting and reporter engagement in patient safety events.

Main Methods:

• Referenced Norman's task action theory and fall management programs.
• Developed a gap-bridging model for user-centered design in reporting systems.
• Created interface artifacts to facilitate user progression through reporting stages.

Main Results:

• The proposed model effectively describes the process of assisting users across all reporting stages.
• Developed interface artifacts act as gap-bridging features.
• These features show potential for improving reporting quality and reporter engagement.

Conclusions:

• A user-centered, gap-bridging model can significantly enhance patient safety event reporting systems.
• Addressing information gaps improves the iterative flow of learning from medical errors.
• The developed system design holds promise for creating a safer healthcare environment through better reporting practices.