Development and Usability Testing of a System to Detect Adverse Events and Medical Mistakes.

Area of Science:

• Health Informatics
• Patient Safety
• Quality Improvement

Background:

• Adverse events during inpatient hospital visits incur significant personal and financial costs.
• Vulnerable populations experience a disproportionate number of adverse events.
• Existing methods like the Institute for Healthcare Improvement Global Trigger Tool rely on retrospective chart review, limiting proactive intervention.

Purpose of the Study:

• To gather usability feedback on a prototype electronic Global Trigger Tool (e-GTT).
• To assess the potential of an informatics intervention for identifying adverse event risk factors.
• To inform the development of scalable and prospective patient safety tools.

Main Methods:

• Interviewed six health professionals (clinical, quality improvement, research roles) who are potential users.
• Collected usability feedback on a prototype e-GTT designed to collect and present adverse event risk factors.
• Assessed user perceptions of current adverse event tracking methods.

Main Results:

• Interviewees confirmed insufficiencies in current adverse event tracking methods.
• Users provided valuable input on desired future user interface features for the e-GTT.
• Universal agreement on the need for improved, prospective patient safety tools.

Conclusions:

• The prototype electronic Global Trigger Tool shows promise as an informatics intervention.
• User feedback is crucial for refining the e-GTT and enhancing its clinical utility.
• Integration into electronic health record systems is a key next step for improving patient safety modules.