University of Glasgow, UK.
Health Informatics J. 2020 Jun;26(2):1017-1042. doi: 10.1177/1460458219859992. Epub 2019 Jul 16.
Different accident analytical approaches have been utilised in safety-critical industries for analysing accidents and formulating safety recommendations. This study presents a 'health informatics' case incident of a patient adversely affected due to a medication dosing error resulting from a combination of contributing factors including those relating to the Computerised Order Provider Entry System. A comparative study was carried out using selected accident analytical approaches: Human Factors and Classification System, System-Theoretic Accident Modelling and Processes and Accident Modelling. Each resulting output was compared using the model characteristic criteria developed by Underwood and Waterson. Safety recommendations developed based on the outputs from the models/methods were also compared for any similar findings. It was acknowledged that while accident models incorporating 'systems thinking' can prove to be beneficial for healthcare in providing insight on systemic factors, there is a need for improving the reliability and validity of these models. This particularly applies to Rasmussen's Accident Modelling approach to be considered useful in the healthcare domain.
不同的事故分析方法已被应用于安全关键型行业，以分析事故并制定安全建议。本研究提出了一个“健康信息学”案例事件，一名患者因用药剂量错误而受到不良影响，这是多种因素共同作用的结果，包括与计算机医嘱输入系统有关的因素。本研究使用了选定的事故分析方法进行了比较研究：人为因素和分类系统、系统理论事故建模和过程以及事故建模。使用 Underwood 和 Waterson 开发的模型特征标准对每个结果输出进行了比较。还比较了基于模型/方法输出制定的安全建议，以寻找任何相似的发现。虽然包含“系统思维”的事故模型可以为医疗保健提供有关系统因素的深入了解，但需要提高这些模型的可靠性和有效性。这尤其适用于 Rasmussen 的事故建模方法，需要考虑其在医疗保健领域的有用性。
