BACKGROUND: In 2000, the Institute of Medicine reported disturbing numbers on the scope it covers and the impact of medical error in the process of health delivery. Nevertheless, a solution to this problem may lie on the adoption of adverse event reporting and learning systems that can help to identify hazards and risks. It is crucial to apply models to identify the adverse events root causes, enhance the sharing of knowledge and experience. The efficiency of the efforts to improve patient safety has been frustratingly slow. Some of this insufficiency of progress may be assigned to the lack of systems that take into account the characteristic of the information about the real world. In our daily lives, we formulate most of our decisions normally based on incomplete, uncertain and even forbidden or contradictory information. One's knowledge is less based on exact facts and more on hypothesis, perceptions or indications. PURPOSE: From the data collected on our adverse event treatment and learning system on medical imaging, and through the use of Extended Logic Programming to knowledge representation and reasoning, and the exploitation of new methodologies for problem solving, namely those based on the perception of what is an agent and/or multi-agent systems, we intend to generate reports that identify the most relevant causes of error and define improvement strategies, concluding about the impact, place of occurrence, form or type of event recorded in the healthcare institutions. RESULTS AND CONCLUSIONS: The Eindhoven Classification Model was extended and adapted to the medical imaging field and used to classify adverse events root causes. Extended Logic Programming was used for knowledge representation with defective information, allowing for the modelling of the universe of discourse in terms of data and knowledge default. A systematization of the evolution of the body of knowledge about Quality of Information embedded in the Root Cause Analysis was accomplished. An adverse event reporting and learning system was developed based on the presented approach to medical errors in imaging. This system was deployed in two Portuguese healthcare institutions, with an appealing outcome. The system enabled to verify that the majority of occurrences were concentrated in a few events that could be avoided. The developed system allowed automatic knowledge extraction, enabling report generation with strategies for the improvement of quality-of-care.
BACKGROUND: In 2000, the Institute of Medicine reported disturbing numbers on the scope it covers and the impact of medical error in the process of health delivery. Nevertheless, a solution to this problem may lie on the adoption of adverse event reporting and learning systems that can help to identify hazards and risks. It is crucial to apply models to identify the adverse events root causes, enhance the sharing of knowledge and experience. The efficiency of the efforts to improve patient safety has been frustratingly slow. Some of this insufficiency of progress may be assigned to the lack of systems that take into account the characteristic of the information about the real world. In our daily lives, we formulate most of our decisions normally based on incomplete, uncertain and even forbidden or contradictory information. One's knowledge is less based on exact facts and more on hypothesis, perceptions or indications. PURPOSE: From the data collected on our adverse event treatment and learning system on medical imaging, and through the use of Extended Logic Programming to knowledge representation and reasoning, and the exploitation of new methodologies for problem solving, namely those based on the perception of what is an agent and/or multi-agent systems, we intend to generate reports that identify the most relevant causes of error and define improvement strategies, concluding about the impact, place of occurrence, form or type of event recorded in the healthcare institutions. RESULTS AND CONCLUSIONS: The Eindhoven Classification Model was extended and adapted to the medical imaging field and used to classify adverse events root causes. Extended Logic Programming was used for knowledge representation with defective information, allowing for the modelling of the universe of discourse in terms of data and knowledge default. A systematization of the evolution of the body of knowledge about Quality of Information embedded in the Root Cause Analysis was accomplished. An adverse event reporting and learning system was developed based on the presented approach to medical errors in imaging. This system was deployed in two Portuguese healthcare institutions, with an appealing outcome. The system enabled to verify that the majority of occurrences were concentrated in a few events that could be avoided. The developed system allowed automatic knowledge extraction, enabling report generation with strategies for the improvement of quality-of-care.
Authors: Babiche E J M Driesen; Mees Baartmans; Hanneke Merten; René Otten; Camilla Walker; Prabath W B Nanayakkara; Cordula Wagner Journal: J Patient Saf Date: 2021-10-13 Impact factor: 2.243