Development and Implementation of The University of Texas Close Call Reporting System

Abstract

This report describes the development and implementation of The University of Texas Close Call Reporting System (UTCCRS), an anonymous tool used to collect information about potential errors that do not reach the patient. The system was originally developed through experimentation, using a fund of knowledge collected in the aviation industry. A multidisciplinary health care team adapted this approach to develop a close call categorization scheme based on human factor principles. This system, which is available in Web-based and paper formats, allows reporters to submit close calls in a risk-free manner and to enable the collection of rich information about the etiology of close calls. This information is used to identify areas of vulnerability and to develop interventions that can prevent problems from recurring. The development and implementation processes presented in this paper provide a comprehensive framework that can be used for future deployments of similar patient safety systems. Phase 1, System Development, discusses the issues that are important to consider when developing a reporting system: (1) a definition of a close call; (2) potential barriers that might be encountered with a close call reporting system (i.e., whether reporting should be anonymous or confidential); (3) possible modalities of the system (i.e., paper, phone, electronic); (4) feedback mechanisms to reporters; and (5) the format and content of the system. In Phase 2, Consensus about Content, the work team developed the close call categories of blood/transfusion, diagnostic test/procedure, equipment/devices, falls, medication, other treatment, surgery, therapeutic procedures, and contributing factors. The paper also describes Phase 3, the Development of the Prototype System, and Phase 4, Implementation.

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Document Details

Document Type
Technical Report
Publication Date
May 01, 2005
Accession Number
ADA434086

Entities

People

  • Debora Simmons
  • Jason M. Etchegaray
  • Kelly Clark
  • Sharon K. Martin
  • W. T. Belt

Organizations

  • United States Agency for Healthcare Research and Quality

Tags

Communities of Interest

  • Biomedical

DTIC Thesaurus Topics

  • Computers
  • Database Management Systems
  • Databases
  • Department Of Veterans Affairs
  • Education
  • Electronic Mail
  • Failure Mode And Effect Analysis
  • Health
  • Health Care
  • Health Services
  • Information Systems
  • Lessons Learned
  • Medical Personnel
  • Standards
  • Training
  • Universities
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Fields of Study

  • Computer science

Readers

  • Clinical Trial Research.
  • Educational Psychology
  • Systems Analysis and Design

Technology Areas

  • Microelectronics