Development and representation of a fall-injury risk assessment instrument in a clinical information system.

The potential for informatics solutions to address inpatient safety issues is significant; however, several challenges are associated with the development of patient safety related informatics applications. These challenges include: 1) the identification and/or development of valid and reliable instruments; 2) adequate representation of key safety concepts, constructs, and associated concepts in the clinical information system; and 3) identification of data sources for instrument pre-population. As part of a larger project aimed at identifying and addressing the information needs of clinicians while using a clinical information system, an electronic fall and injury risk assessment instrument is in development to address a hospital-based fall and injury prevention initiative. The concepts contained in the instrument are well represented by Clinical LOINC and the UMLS. Associated concepts have been identified in the existing clinical information system data dictionary for pre-population of the instrument.