Abstract
Recently, frequent problems with patient safety have occurred in Japan due to overlooking radiogram interpretation reports (hereinafter, overlooking problem), and many hospitals have reported countermeasures. If the countermeasure information could be organized systematically, meaningful findings may be obtained and patient safety can be maintained. However, it is difficult to extract and organize written information from the literatures composed and described in a different manner. Nevertheless, the difficulty in organizing the literature is not specific to the overlooking problem and is common to most healthcare information systems. Therefore, in this study, we generalized the overlooking problem to “problems caused by user behavior” in medical practices with “hospital independent work flow” and assumed that there were many cases in the literature discussing these problems. Then, we proposed a general method for deriving (a) case causes, (b) case countermeasures, and (c) a general-purpose model to examine the countermeasure frameworks from the above cases.
The usefulness of the proposed method was discussed by applying it to overlooked problems and examining whether meaningful findings could be obtained. Specifically, 62 literature cases from 48 hospitals extracted using Ichushi-Web and three academic journals containing many publications on overlooked problems were analyzed using the proposed method. As a result, the expected outcomes (a) to (c) could be obtained despite 74％ of the cases being abstracts described in ≤ 1,000 characters. The two key terms, “hospital independent work flow” and “problems caused by user behavior”, were important in that the proposed method worked effectively in this situation. Furthermore, our results suggested that the proposed method could be flexibly applied to similar problems.
