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A prototype of knowledge-based patient safety event reporting and learning system.

Hong Kang1, Sicheng Zhou1, Bin Yao1

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This study introduces a novel patient fall reporting system that enhances knowledge sharing and learning. The system effectively supports healthcare professionals in identifying contributing factors and accessing solutions, improving patient safety event reporting.

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Area of Science:

  • Healthcare Safety
  • Patient Fall Prevention
  • Knowledge Management Systems

Background:

  • Patient falls are a leading cause of adverse events in healthcare, incurring significant costs and burdens.
  • Current patient fall reporting systems are inadequate, hindering the achievement of optimal healthcare safety.
  • A critical gap exists in knowledge management, sharing, and growth, impeding the learning stage of patient safety event analysis.

Purpose of the Study:

  • To develop a novel reporting system for patient falls that facilitates knowledge sharing and learning.
  • To establish a hierarchical list of contributing factors for patient falls based on expert consensus.
  • To provide reporters with knowledge support, including similar cases and potential solutions, to improve reporting.

Main Methods:

  • A hierarchical list of contributing factors for patient falls was created using expert review and discussion, based on AHRQ Common Formats 2.0.
  • A novel reporting system was designed and developed, incorporating a strategy to identify contributing factors and offer knowledge support.
  • A survey with two scenarios was conducted to evaluate the learning effectiveness of the developed system.

Main Results:

  • Potential solutions recommended by the system were accurately annotated with contributing factors and presented contextually.
  • Experts demonstrated substantial consistency (Fleiss' kappa > 0.6) and high agreement in assessing the system's effectiveness.
  • The study verified the effectiveness of the proposed knowledge support in promoting sharing and learning through the novel reporting system.

Conclusions:

  • A profile of contributing factors was proposed to measure the similarity of patient safety events.
  • A knowledge-based reporting and learning system was developed to integrate surveillance, reporting, and retrospective analysis in fall management.
  • The developed system shows promise for enhancing event reporting and contributing to safer healthcare practices.