%0 Journal Article
%T Web-Based Meaningful Reporting of Patient Harm: Proposal of a Prototype for Creating High Reliability Hospitals
%A Ranjit Singh
%A Raj Sharman
%A Gayatri Umesh
%A K. V. Sankarasubramaniam
%A Srikanth Parmeswaran
%A Arun Nararayan
%J Open Access Library Journal
%V 2
%N 1
%P 1-8
%@ 2333-9721
%D 2015
%I Open Access Library
%R 10.4236/oalib.1101287
%X Background: Healthcare settings require a system
that detects errors and near misses and learns from them to prevent their
reoccurrence. Development of such a system requires engagement of all stakeholders.
Retrospective reporting, analyzing and preventing future errors is currently
the most prevalent approach to reducing harm to patients. It is important to
point out that a recent report regarding reporting by the US Department of
Health and Human Services Office of the Inspector General to Congress suggests
that ¡°current methods of detection of adverse events are far from adequate and
risk misdirection of present efforts to improve safety based quality¡±. Recommended
Approach: In an approach to overcome numerous limitations of current reporting
methods, the authors propose a web-based user-friendly method that helps
engagement of all stakeholders. Whilst invoking ¡°improvement science¡± with ¡°design
science¡± it applies safety principles. It enables meaningful reporting that
applies concepts from organizational models of accidents (based on Reason¡¯s
Trajectory). The design and use features are described in detail. Conclusion:
Pilot tests with this reporting tool have been very encouraging. This
trajectory model appears to help reporters to detect and understand that most
accidents can be attributed to one or more of three weaknesses: <i>situational</i>,<i> latent</i>, and <i>active</i>.
%K Barriers to Reporting
%K Reliability
%K Safety
%K System
%K Trajectory
%U http://www.oalib.com/paper/3134500