Borycki E M, Kushniruk A W, Keay L, Kuo A
School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada.
Stud Health Technol Inform. 2009;148:181-7.
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.
健康信息系统有能力减少医疗差错，但它们也可能引入新类型的差错。在认知和人为因素文献中，人们认识到，医疗行业以外的其他行业发生的许多备受瞩目的事故都源于组织工作的复杂性以及工作的组织方式。作者们提出，为了拥有一个全面稳健的框架来诊断技术引发的差错，必须使用多组织模型来理解一项技术的开发与实施以及政策的影响。作者们提出，技术引发的差错除了医疗服务提供者之外，可能源于构成复杂医疗系统的多达四个或更多的组织结构：政府、示范组织、软件开发组织和当地医疗组织。本文提出了一个用于思考医疗保健中技术引发差错根源的框架，以及我们迄今为止在应用该框架方面的经验。
