Background: Patient falls, the most common safety events resulting in adverse patient outcomes, impose\nsignificant costs and have become a great burden to the healthcare community. Current patient fall reporting\nsystems remain in the early stage that is far away from reaching the ultimate goal toward a safer healthcare.\nAccording to the Kirkpatrick model, the key challenge in reaction, learning, behavior and results is the realization of\nlearning stage due to the lack of knowledge management, sharing and growing mechanism.\nMethods: Based on the key contributing factors defined by AHRQ Common Formats 2.0, a hierarchical list of\ncontributing factors for patient falls was established by expert review and discussion. Using the list as an\ninfrastructure, we designed and developed a novel reporting system, where a strategy to identify contributing\nfactors is intended to provide reporters knowledge support, in the form of similar cases and potential solutions. A\nsurvey containing two scenarios was conducted to evaluate the learning effect of our system.\nResults: In both scenarios, potential solutions recommended by the system were annotated with correct\ncontributing factors, and presented only when the corresponding factors were identified from the query report or\nselected by the user. The five experts show substantial consistency (Fleissâ?? kappa > 0.6) and high agreement\n(ranging between fully agree and mostly agree) in the assessment of the three perspectives of the system, which\nverifies the effectiveness of the proposed knowledge support toward sharing and learning through the novel\nreporting system.\nConclusions: This study proposed a profile of contributing factors that could measure the similarity of patient\nsafety events. Based on the profile, a knowledge-based reporting and learning system was developed to bridge the\ngap between surveillance, reporting, and retrospective analysis in the fall management circle. The system holds\npromise in improving event reporting toward better and safer healthcare.
Loading....