Analyzing medical incident reports in the context of medical care processes

In its 2004 report, "Patient Safety, Achieving a New Standard for Care," the US Institute of Medicine stated that "patient safety systems [should] integrate with clinical information systems." Recommendation one in this report was that "Improved information and data systems are needed to support efforts to make patient safety a standard of care" and that all healthcare organizations should "capture information on patient safety... and use this information to design even safer care delivery systems." Medical incident reports typically indicate the harm (or precursor to harm), staff roles involved and potential causes related to the incident. We have hypothesized that it is also necessary to more explicitly model, and identify in (or extract from) incident reports the portions of the healthcare process that were involved in the incident; so that the parts of the process contributing to the incidents can be redesigned or modified to improve safety (e.g., reduce risk). This paper presents a conceptual framework relating incident reports to the healthcare processes and some preliminary analysis results. The results are based on incident reports collected by Johns Hopkins University Quality and Safety Research Group for a project that has established an ICU Safety Reporting System (ICUSRS) in partnership with the Society for Critical Care Medicine (SCCM) and the use of data visualization tools.