Nursing and Social Care Information Directorate, NHS Wales Informatics Service, Pencoed, Wales, UK.
Appl Clin Inform. 2012 Jun 27;3(2):248-57. doi: 10.4338/ACI-2012-03-RA-0010. Print 2012.
Interest in the field of patient safety incident reporting and analysis with respect to Health Information Technology (HIT) has been growing over recent years as the development, implementation and reliance on HIT systems becomes ever more prevalent. One of the rationales for capturing patient safety incidents is to learn from failures in the delivery of care and must form part of a feedback loop which also includes analysis; investigation and monitoring. With the advent of new technologies and organizational programs of delivery the emphasis is increasingly upon analyzing HIT incidents. This thematic review had two objectives, to test the applicability of a framework specifically designed to categorize HIT incidents and to review the Welsh incidents as communicated via the national incident reporting system in order to understand their implications for healthcare. The incidents were those reported as IT/ telecommunications failure/ overload. Incidents were searched for within a national reporting system using a standardized search strategy for incidents occurring between 1(st) January 2009 and 31(st) May 2011. 149 incident reports were identified and classified. The majority (77%) of which were machine related (technical problems) such as access problems; computer system down/too slow; display issues; and software malfunctions. A further 10% (n = 15) of incidents were down to human-computer interaction issues and 13% (n = 19) incidents, mainly telephone related, could not be classified using the framework being tested. On the basis of this review of incidents, it is recommended that the framework be expanded to include hardware malfunctions and the wrong record retrieved/missing data associated with a machine output error (as opposed to human error). In terms of the implications for clinical practice, the incidents reviewed highlighted critical issues including the access problems particularly relating to the use of mobile technologies.
近年来，随着医疗信息技术（HIT）的发展、实施和依赖程度越来越高，人们对与 HIT 相关的患者安全事件报告和分析领域的兴趣日益浓厚。捕捉患者安全事件的原因之一是要从护理服务的失败中吸取教训，这必须成为反馈循环的一部分，该反馈循环还包括分析、调查和监测。随着新技术和新的组织交付计划的出现，重点越来越多地放在分析 HIT 事件上。本次专题审查有两个目标，一是测试专门设计用于对 HIT 事件进行分类的框架的适用性，二是审查通过国家事件报告系统通报的威尔士事件，以了解其对医疗保健的影响。这些事件是指报告的 IT/电信故障/过载事件。在全国报告系统中，使用针对 2009 年 1 月 1 日至 2011 年 5 月 31 日期间发生的事件的标准化搜索策略，对事件进行搜索。共确定并分类了 149 起事件报告。其中大多数（77%）与机器相关（技术问题），例如访问问题；计算机系统关闭/太慢；显示问题；和软件故障。另有 10%（n=15）的事件是由于人机交互问题，而 13%（n=19）的事件，主要与电话相关，无法使用正在测试的框架进行分类。基于对事件的审查，建议扩展框架，将硬件故障以及与机器输出错误（而不是人为错误）相关的错误记录检索/缺少数据包括在内。就对临床实践的影响而言，所审查的事件突出了一些关键问题，包括访问问题，特别是与移动技术的使用有关的问题。
