A framework for diagnosing and identifying where technology-induced errors come from.
Health information systems have the ability to reduce medical errors but they can also introduce new types of errors. In the cognitive and human factors literature there is a recognition that many of the high profile accidents that have occurred in other industries outside of healthcare have had their origins in the complexities of organizational work and how work is structured. The authors propose that in order to have a fully robust framework for diagnosing technology-induced errors one must understand the development and implementation of a technology and the influences of policy using a multi-organizational model. The authors propose that technology-induced errors may have their origins in up to four or more organizational structures that make up complex health care systems in addition to the health care provider: governments, model organizations, software development organizations, and local healthcare organizations. In this paper a framework for considering the origins of technology-induced error in healthcare is presented, along with our experiences to date in the application of the framework.
Borycki
E M
EM
School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada. emb@uvic.ca
Kushniruk
A W
AW
Keay
L
L
Kuo
A
A
D006801:Humans; D008490:Medical Informatics; D008508:Medication Errors / Q000517:prevention & control*; D017146:Models, Organizational; D016134:Organizational Policy; D012308:Risk Management / Q000379:methods*; D017751:Safety Management; D014584:User-Computer Interface