2020 Volume 40 Issue 3 Pages 125-144
Patient safety problems arising from overlooking radiogram interpretation reports (hereinafter “overlooking problem”) can in principle occur at any hospital. In fact, many hospitals throughout Japan have reported the causes of and countermeasures to the problems, but such valuable information, knowledge and experience are dispersed. Therefore, it would be highly important to organize the dispersed reports systematically for hospitals with or without established forms of countermeasure. In previous research, the author has proposed a method to obtain wisdom by systematically consolidating the information contained in the reports. Then, the proposed method was applied to 62 reports discussed about the overlooking problem to obtain “ (1) a causal events casebook” and (2) a general-purpose model for consideration of the hospital countermeasure framework”. Here, the latter consists of “basic elements of countermeasure” which obtained by coarse-graining each hospital countermeasures from the viewpoint of 6W1H, and aggregating similar elements.
The above product (2) can not only provide support for countermeasure design by hospitals, but can also facilitate derivation of a support system encompassing the countermeasures of all target hospitals. Therefore, using the above products (1) and (2), we proceed to derive the functional requirements for a support system (hereinafter, “comprehensive support system”) for prevention of overlooking problem, encompassing various types of hospital countermeasures from small-to large-scale.
The functional requirements were obtained using four procedures. (a) In order to reduce un-interpreted reports as much as possible, we extracted system-based “basic elements of countermeasure” from the product (2) and defined it as the “core function” of the comprehensive support system. (b) For hospitals that use just part of the core function and combine it with human-based countermeasures, we extracted from the product (2) the human-based “basic elements of countermeasure” and added them to the functional requirements. (c) We added functional requirements to deal with the final un-interpreted reports after implementing countermeasures using functions (a) and/or (b). (d) In the procedures (a) to (c), the functional requirements were configured so that various problems of the product (1) could be comprehensively improved. At that time, the functional requirements were adjusted depending on whether the relationship of the basic elements was “competition, coexistence, or cooperation”.
As a result of the above procedures, we derived the functional requirements of the comprehensive support system comprising 25 system-based segments that constitute the 6 core functions and 6 related human-based segments, plus 2 other segments, resulting in a total of 33 segments. These functional requirements not only comprehensively include the countermeasures implemented by the various hospitals, but can also suggest an answer to the question of “how should one design a system that makes it possible to flexibly modify the countermeasure pattern of a hospital in accordance with its own operational state”.
