信息技术相关医疗不良事件Information Technology-related Medical Adverse Events
曾可;王玉;朱卫国;
ZENG Ke;WANG Yu;ZHU Wei-guo;Department of Information Management,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College;Department of Primary Care and Family Medicine,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College;
摘要(Abstract):
随着信息技术在医疗领域的深入应用,信息技术相关的医疗不良事件也不断增加。本文对国内外信息技术相关医疗不良事件的术语、概念和研究现状进行梳理,从事件表现形式、系统组成要素、事件根本原因3方面进行分类,并给出相应界定和案例说明;同时结合国内外相关研究,进一步探讨信息技术相关医疗不良事件的应对策略,提出提高重视程度、鼓励上报以及建立规范化防范体系等解决方案,以期提高医疗行业对此类不良事件的认识和关注。
With the deep application of information technology in the medical field, the number of information technology-related medical adverse events has been increasing. In this paper, the terms, concepts, and research status of medical adverse events related to information technology were reviewed and classified from three aspects: manifestation, system composition, and error causes. And the corresponding definitions and case descriptions were discussed. Based on relevant research in China and abroad, this paper further explored the counter measures for information technology-related medical adverse events, and proposes solutions to enhance attention, encourage reporting, and establish a standardized prevention system. Hopefully, this review will get more attention of medical industry to information technology-related medical adverse events and provide knowledge and reference for relevant research.
关键词(KeyWords):
医疗信息技术;信息系统;医疗不良事件;医疗差错;技术危害
health information technology;information system;medical adverse events;medical error;technical hazards
基金项目(Foundation): 中国医学科学院医学与健康科技创新工程“医学大数据信息采集和分析评估”(2016-I2M-2-004);中国医学科学院罕见病研究中心HLH精准医学系统的建设及应用示范(2016ZX310174-4)
作者(Author):
曾可;王玉;朱卫国;
ZENG Ke;WANG Yu;ZHU Wei-guo;Department of Information Management,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College;Department of Primary Care and Family Medicine,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College;
Email:
DOI:
参考文献(References):
- [1] 魏斌,田卓平.医疗不良事件SH9分类法及其现实意义[J].中国医院,2011,15:44- 45.
- [2] Schreiber M,Klingelhfer D,Groneberg DA,et al.Patient safety:the landscape of the global research output and gender distribution[J].BMJ Open,2016,6:8322.
- [3] Makary MA,Daniel M.Medical error—the third leading cause of death in the US[J].BMJ,2016,353:2139.
- [4] Radley DC,Wasserman MR,Olsho LE,et al.Reduction in medication errors in hospitals due to adoption of com-puterized provider order entry systems[J].J Am Med Inform Assoc,2013,20:470- 476.
- [5] Poon EG,Keohane CA,Yoon CS,et al.Effect of bar-code technology on the safety of medication administration[J].N Engl J Med,2010,362:1698- 1707.
- [6] Cheung KC,van der Veen W,Bouvy ML,et al.Classification of medication incidents associated with information technology[J].J Am Med Inform Assoc,2014,21:e63- e70.
- [7] Kang H,Yu Z,Gong Y.Initializing and Growing a Database of Health Information Technology (HIT) Events by Using TF-IDF and Biterm Topic Modeling[J].AMIA Annu Symp Proc,2017,1024- 1033.
- [8] Casey R,Ike S.IBM's Watson supercomputer recommended ‘unsafe and incorrect’ cancer treatments,internal do-cuments show [EB/OL].https://www.statnews.com/2018/07/25/ibm-watson-recommended-unsafe-incorrect-treat-ments/,2018- 07- 25.
- [9] Borycki E.Trends in Health Information Technology Safety:From Technology-Induced Errors to Current Approaches for Ensuring Technology Safety[J].Healthc Inform Res,2013,19:69- 78.
- [10] Kushniruk AW,Triola MM,Borycki EM,et al.Technology induced error and usability:the relationship between usability problems and prescription errors when using a handheld application[J].Int J Med Inform,2005,74:519- 526.
- [11] Borycki E,Kushniruk A.Identifying and preventing technology-induced error using simulations:application of usability engineering techniques[J].Healthc Q,2005,8:99- 105.
- [12] Brushwood DB,Winterstein A.Manufacturer warnings of system-related medication errors[J].Am J Health Syst Pharm,2002,59:1110- 1112.
- [13] Ash JS,Berg M,Coiera E.Some unintended consequences of information technology in health care:the nature of patient care information system-related errors[J].J Am Med Inform Assoc,2004,11:104- 112.
- [14] Voight PE.Using safety tools to prevent system-related errors[J].AORN J,2009,89:969- 970.
- [15] Weiner JP,Kfuri T,Chan K,et al.“e-Iatrogenesis”:The Most Critical Unintended Consequence of CPOE and other HIT[J].J Am Med Inform Assoc,2007,14:387- 388.
- [16] Palmieri PA,Peterson LT,Ford EW.Technological iatrogenesis:new risks force heightened management awareness[J].J Healthc Risk Manag,2007,27:19- 24.
- [17] Abramson EL,Kern LM,Brenner S,et al.Expert panel evaluation of health information technology effects on adverse events[J].J Eval Clin Pract,2014,20:375- 382.
- [18] Borycki EM,Kushniruk AW,Keay L,et al.A framework for diagnosing and identifying where technology-induced errors come from[J].Stud Health Technol Inform,2009,148:181- 187.
- [19] ECRI Institute's Health Devices Group.Top 10 Health Technology Hazards for 2018[EB/OL].https://www.ecri.org/search-results/member-preview/hdjournal/pages/top_10_hazards_for_2018/.
- [20] Fred S,Erika F.Death By 1,000 Clicks:Where Electronic Health Records Went Wrong[EB/OL].https://www.physicianspractice.com/article/death-1000-clicks-where-electro-nic- health-records-went-wrong.
- [21] Bellwood P.Qualitative Study of Technology-Induced Errors in Healthcare Organizations [D].Canada:M.Sc.University of Victoria,2011.
- [22] U.S.Food and Drug Administration.MAUDE-Manufacturer and User Facility Device Experience [EB/OL].https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/sea- rch.cfm.
- [23] Kang H,Yu Z,Gong Y.Initializing and Growing a Database of Health Information Technology (HIT) Events by Using TF-IDF and Biterm Topic Modeling[J].AMIA Annu Symp Proc,2018,2017:1024- 1033.
- [24] Yao B,Kang H,Wang J,et al.Exploring Health Infor-mation Technology Events from FDA MAUDE Database[J].Stud Health Technol Inform,2018,250:187- 191.
- [25] 李瑞,梁志刚,李小莹,等.患者身份识别信息不良事件根本原因分析[J].中国病案,2014,15:52- 54.
- [26] 王小平,董钏,蒋庆丽,等.电脑安置床位患者身份信息识别错误根本原因分析[J].世界最新医学信息文摘,2016,16:95- 96.
- [27] Westbrook JI,Baysari MT,Li L,et al.The safety of electronic prescribing:manifestations,mechanisms,and rates of system-related errors associated with two commercial systems in hospitals[J].J Am Med Inform Assoc,2013,20:1159- 1167.
- [28] Magrabi F,Ong MS,Runciman W,et al.Using FDA reports to inform a classification for health information technology safety problems[J].J Am Med Inform Assoc,2012,19:45- 53.
- [29] Borycki E,Dexheimer JW,Hullin Lucay Cossio C,et al.Methods for Addressing Technology-Induced Errors:The Current State[J].Yearb Med Inform,2016,(1):30- 40.
- 医疗信息技术
- 信息系统
- 医疗不良事件
- 医疗差错
- 技术危害
health information technology - information system
- medical adverse events
- medical error
- technical hazards
- 曾可
- 王玉
- 朱卫国
ZENG Ke- WANG Yu
- ZHU Wei-guo
- Department of Information Management
- Peking Union Medical College Hospital
- Chinese Academy of Medical Sciences & Peking Union Medical College
- Department of Primary Care and Family Medicine
- Peking Union Medical College Hospital
- Chinese Academy of Medical Sciences & Peking Union Medical College
- 曾可
- 王玉
- 朱卫国
ZENG Ke- WANG Yu
- ZHU Wei-guo
- Department of Information Management
- Peking Union Medical College Hospital
- Chinese Academy of Medical Sciences & Peking Union Medical College
- Department of Primary Care and Family Medicine
- Peking Union Medical College Hospital
- Chinese Academy of Medical Sciences & Peking Union Medical College