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Volumn 18, Issue 3, 2011, Pages 259-266

A simulation framework for mapping risks in clinical processes: The case of in-patient transfers

Author keywords

[No Author keywords available]

Indexed keywords

ADVERSE OUTCOME; ARTICLE; CALIBRATION; CLINICAL PROTOCOL; CONCEPTUAL FRAMEWORK; HOSPITAL MANAGEMENT; HOSPITAL PATIENT; HUMAN; IN PATIENT TRANSFER; INFECTION CONTROL; INFECTION RISK; INFORMATION SYSTEM; MEDICAL PRACTICE; OUTCOME ASSESSMENT; PATIENT IDENTIFICATION; PATIENT TRANSPORT; PHYSICIAN; RISK ASSESSMENT; SIMULATION; WORKFLOW;

EID: 79958248023     PISSN: 10675027     EISSN: 1527974X     Source Type: Journal    
DOI: 10.1136/amiajnl-2010-000075     Document Type: Article
Times cited : (16)

References (54)
  • 1
    • 47749130878 scopus 로고    scopus 로고
    • The incidence and nature of in-hospital adverse events: a systematic review
    • de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008;17:216-23.
    • (2008) Qual Saf Health Care , vol.17 , pp. 216-223
    • de Vries, E.N.1    Ramrattan, M.A.2    Smorenburg, S.M.3
  • 2
    • 60849083353 scopus 로고    scopus 로고
    • Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study
    • Zegers M, de Bruijne MC, Wagner C, et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care 2009;18:297-302.
    • (2009) Qual Saf Health Care , vol.18 , pp. 297-302
    • Zegers, M.1    de Bruijne, M.C.2    Wagner, C.3
  • 4
    • 35648979464 scopus 로고    scopus 로고
    • Multimethod evaluation of information and communication technologies in health in the context of wicked problems and sociotechnical theory
    • Westbrook JI, Braithwaite J, Georgiou A, et al. Multimethod evaluation of information and communication technologies in health in the context of wicked problems and sociotechnical theory. J Am Med Inform Assoc 2007;14:746-55.
    • (2007) J Am Med Inform Assoc , vol.14 , pp. 746-755
    • Westbrook, J.I.1    Braithwaite, J.2    Georgiou, A.3
  • 5
    • 71849110056 scopus 로고    scopus 로고
    • New approaches to researching patient safety
    • Iedema R. New approaches to researching patient safety. Soc Sci Med 2009;69:1701-4.
    • (2009) Soc Sci Med , vol.69 , pp. 1701-1704
    • Iedema, R.1
  • 6
    • 33750682305 scopus 로고    scopus 로고
    • The need for organizational change in patient safety initiatives
    • Anderson JG, Ramanujam R, Hensel D, et al. The need for organizational change in patient safety initiatives. Int J Med Inform 2006;75:809-17.
    • (2006) Int J Med Inform , vol.75 , pp. 809-817
    • Anderson, J.G.1    Ramanujam, R.2    Hensel, D.3
  • 7
    • 65349159498 scopus 로고    scopus 로고
    • A system analysis of a suboptimal surgical experience
    • Lee R, Cooke D, Richards M. A system analysis of a suboptimal surgical experience. Patient Saf Surg 2009;3:1.
    • (2009) Patient Saf Surg , vol.3 , pp. 1
    • Lee, R.1    Cooke, D.2    Richards, M.3
  • 8
    • 7044242917 scopus 로고    scopus 로고
    • Perceived information needs and communication difficulties of inpatient physicians and nurses
    • McKnight LK, Stetson PD, Bakken S, et al. Perceived information needs and communication difficulties of inpatient physicians and nurses. J Am Med Inform Assoc 2002;9(6 Suppl 1):S64-9.
    • (2002) J Am Med Inform Assoc , vol.9 , Issue.6 SUPPL. 1
    • McKnight, L.K.1    Stetson, P.D.2    Bakken, S.3
  • 9
    • 33847392867 scopus 로고    scopus 로고
    • Stopping the error cascade: a report on ameliorators from the ASIPS collaborative
    • Parnes B, Fernald D, Quintela J, et al. Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. Qual Saf Health Care 2007;16:12-16.
    • (2007) Qual Saf Health Care , vol.16 , pp. 12-16
    • Parnes, B.1    Fernald, D.2    Quintela, J.3
  • 10
    • 0036718584 scopus 로고    scopus 로고
    • Evaluating the capability of information technology to prevent adverse drug events: a computer simulation approach
    • Anderson JG, Jay SJ, Anderson M, et al. Evaluating the capability of information technology to prevent adverse drug events: a computer simulation approach. J Am Med Inform Assoc 2002;9:479-90.
    • (2002) J Am Med Inform Assoc , vol.9 , pp. 479-490
    • Anderson, J.G.1    Jay, S.J.2    Anderson, M.3
  • 11
    • 0026022279 scopus 로고
    • The nature of adverse events in hospitalized patients
    • Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. N Engl J Med 1991;324:377-84.
    • (1991) N Engl J Med , vol.324 , pp. 377-384
    • Leape, L.L.1    Brennan, T.A.2    Laird, N.3
  • 12
    • 0033519201 scopus 로고    scopus 로고
    • An analysis of the causes of adverse events from the Quality in Australian Health Care Study
    • Wilson RM, Harrison BT, Gibberd RW, et al. An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Med J Aust 1999;170:411-15.
    • (1999) Med J Aust , vol.170 , pp. 411-415
    • Wilson, R.M.1    Harrison, B.T.2    Gibberd, R.W.3
  • 13
    • 0034450205 scopus 로고    scopus 로고
    • Improving clinical communication: a view from psychology
    • Parker J, Coiera E. Improving clinical communication: a view from psychology. J Am Med Inform Assoc 2000;7:453-61.
    • (2000) J Am Med Inform Assoc , vol.7 , pp. 453-461
    • Parker, J.1    Coiera, E.2
  • 14
    • 4243112808 scopus 로고    scopus 로고
    • A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors
    • Woolf SH, Kuzel AJ, Dovey SM, et al. A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Ann Fam Med 2004;2:317-26.
    • (2004) Ann Fam Med , vol.2 , pp. 317-326
    • Woolf, S.H.1    Kuzel, A.J.2    Dovey, S.M.3
  • 16
    • 0025705937 scopus 로고
    • Human error and the problem of causality in analysis of accidents [and discussion]
    • Rasmussen J, Nixon P, Warner F. Human error and the problem of causality in analysis of accidents [and discussion]. Philos Trans R Soc Lond B Biol Sci 1990;327:449-62.
    • (1990) Philos Trans R Soc Lond B Biol Sci , vol.327 , pp. 449-462
    • Rasmussen, J.1    Nixon, P.2    Warner, F.3
  • 17
    • 0346325831 scopus 로고    scopus 로고
    • Assessing patient safety risk before the injury occurs: an introduction to sociotechnical probabilistic risk modelling in health care
    • Marx DA, Slonim AD. Assessing patient safety risk before the injury occurs: an introduction to sociotechnical probabilistic risk modelling in health care. Qual Saf Health Care 2003;12(Suppl 2):ii33-8.
    • (2003) Qual Saf Health Care , vol.12 , Issue.SUPPL. 2
    • Marx, D.A.1    Slonim, A.D.2
  • 18
    • 70349174310 scopus 로고    scopus 로고
    • Risk analysis by FMEA as an element of analytical validation
    • van Leeuwen JF, Nauta MJ, de Kaste D, et al. Risk analysis by FMEA as an element of analytical validation. J Pharm Biomed Anal 2009;50:1085-7.
    • (2009) J Pharm Biomed Anal , vol.50 , pp. 1085-1087
    • van Leeuwen, J.F.1    Nauta, M.J.2    de Kaste, D.3
  • 19
    • 17144397201 scopus 로고    scopus 로고
    • Use of a systematic risk analysis method to improve safety in the production of paediatric parenteral nutrition solutions
    • Bonnabry P, Cingria L, Sadeghipour F, et al. Use of a systematic risk analysis method to improve safety in the production of paediatric parenteral nutrition solutions. Qual Saf Health Care 2005;14:93-8.
    • (2005) Qual Saf Health Care , vol.14 , pp. 93-98
    • Bonnabry, P.1    Cingria, L.2    Sadeghipour, F.3
  • 20
    • 0036615053 scopus 로고    scopus 로고
    • Failure mode and effect analysis: an application in reducing risk in blood transfusion
    • Burgmeier J. Failure mode and effect analysis: an application in reducing risk in blood transfusion. Jt Comm J Qual Improv 2002;28:331-9.
    • (2002) Jt Comm J Qual Improv , vol.28 , pp. 331-339
    • Burgmeier, J.1
  • 21
    • 33750728434 scopus 로고    scopus 로고
    • Using failure mode and effects analysis for safe administration of chemotherapy to hospitalized children with cancer
    • Robinson DL, Heigham M, Clark J. Using failure mode and effects analysis for safe administration of chemotherapy to hospitalized children with cancer. Jt Comm J Qual Patient Saf 2006;32:161-6.
    • (2006) Jt Comm J Qual Patient Saf , vol.32 , pp. 161-166
    • Robinson, D.L.1    Heigham, M.2    Clark, J.3
  • 22
    • 67349151722 scopus 로고    scopus 로고
    • FMEA: a model for reducing medical errors
    • Chiozza ML, Ponzetti C. FMEA: a model for reducing medical errors. Clin Chim Acta 2009;404:75-8.
    • (2009) Clin Chim Acta , vol.404 , pp. 75-78
    • Chiozza, M.L.1    Ponzetti, C.2
  • 23
    • 0034846239 scopus 로고    scopus 로고
    • Post-operative endophthalmitis: the application of hazard analysis critical control points (HACCP) to an infection control problem
    • Baird DR, Henry M, Liddell KG, et al. Post-operative endophthalmitis: the application of hazard analysis critical control points (HACCP) to an infection control problem. J Hosp Infect 2001;49:14-22.
    • (2001) J Hosp Infect , vol.49 , pp. 14-22
    • Baird, D.R.1    Henry, M.2    Liddell, K.G.3
  • 24
    • 58849149432 scopus 로고    scopus 로고
    • The application of hazard analysis and critical control points and risk management in the preparation of anti-cancer drugs
    • Bonan B, Martelli N, Berhoune M, et al. The application of hazard analysis and critical control points and risk management in the preparation of anti-cancer drugs. Int J Qual Health Care 2009;21:44-50.
    • (2009) Int J Qual Health Care , vol.21 , pp. 44-50
    • Bonan, B.1    Martelli, N.2    Berhoune, M.3
  • 25
    • 79958260241 scopus 로고    scopus 로고
    • The clinical application of hazard analysis critical control points (HACCP)
    • Griffith C, Obee P, Cooper R. The clinical application of hazard analysis critical control points (HACCP). Am J Infect Control 2005;33:e39.
    • (2005) Am J Infect Control , vol.33
    • Griffith, C.1    Obee, P.2    Cooper, R.3
  • 26
    • 2942739051 scopus 로고    scopus 로고
    • Assessing risk: the role of probabilistic risk assessment (PRA) in patient safety improvement
    • Wreathall J, Nemeth C. Assessing risk: the role of probabilistic risk assessment (PRA) in patient safety improvement. Qual Saf Health Care 2004;13:206-12.
    • (2004) Qual Saf Health Care , vol.13 , pp. 206-212
    • Wreathall, J.1    Nemeth, C.2
  • 27
    • 34447340215 scopus 로고    scopus 로고
    • Measuring human-error probabilities in drug preparation: a pilot simulation study
    • Garnerin P, Pellet-Meier B, Chopard P, et al. Measuring human-error probabilities in drug preparation: a pilot simulation study. Eur J Clin Pharmacol 2007;63:769-76.
    • (2007) Eur J Clin Pharmacol , vol.63 , pp. 769-776
    • Garnerin, P.1    Pellet-Meier, B.2    Chopard, P.3
  • 28
    • 45849139772 scopus 로고    scopus 로고
    • Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety
    • Koppel R, Wetterneck T, Telles JL, et al. Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc 2008;15:408-23.
    • (2008) J Am Med Inform Assoc , vol.15 , pp. 408-423
    • Koppel, R.1    Wetterneck, T.2    Telles, J.L.3
  • 29
    • 17144402486 scopus 로고    scopus 로고
    • Ambiguity and workarounds as contributors to medical error
    • Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med 2005;142:627-30.
    • (2005) Ann Intern Med , vol.142 , pp. 627-630
    • Spear, S.J.1    Schmidhofer, M.2
  • 30
    • 84972263711 scopus 로고
    • Intelligent agents: Theory and practice
    • Wooldridge M, Jennings NR. Intelligent agents: Theory and practice. Knowl Eng Rev 1995;10:115-52.
    • (1995) Knowl Eng Rev , vol.10 , pp. 115-152
    • Wooldridge, M.1    Jennings, N.R.2
  • 31
    • 0002158976 scopus 로고    scopus 로고
    • Is it an agent, or just a program?: a taxonomy for autonomous agents
    • Müller JP, Wooldridge MJ, Jennings NR, eds. Berlin: Springer-Verlag
    • Franklin S, Graesser A. Is it an agent, or just a program?: a taxonomy for autonomous agents. In: Müller JP, Wooldridge MJ, Jennings NR, eds. Intelligent Agents III. Berlin: Springer-Verlag, 1997.
    • (1997) Intelligent Agents III
    • Franklin, S.1    Graesser, A.2
  • 34
    • 0031368613 scopus 로고    scopus 로고
    • ACT-R: a theory of higher level cognition and its relation to visual attention
    • Anderson JR, Matessa M, Lebiere C. ACT-R: a theory of higher level cognition and its relation to visual attention. Hum Comput Interact 1997;12:439-62.
    • (1997) Hum Comput Interact , vol.12 , pp. 439-462
    • Anderson, J.R.1    Matessa, M.2    Lebiere, C.3
  • 36
    • 0036150638 scopus 로고    scopus 로고
    • Memory for goals: an activation-based model
    • Altmann EM, Trafton JG. Memory for goals: an activation-based model. Cogn Sci 2002;26:39-83.
    • (2002) Cogn Sci , vol.26 , pp. 39-83
    • Altmann, E.M.1    Trafton, J.G.2
  • 37
    • 39049146131 scopus 로고    scopus 로고
    • Threaded cognition: an integrated theory of concurrent multitasking
    • Salvucci DD, Taatgen NA. Threaded cognition: an integrated theory of concurrent multitasking. Psychol Rev 2008;115:101-30.
    • (2008) Psychol Rev , vol.115 , pp. 101-130
    • Salvucci, D.D.1    Taatgen, N.A.2
  • 38
    • 0000186604 scopus 로고    scopus 로고
    • The GOMS family of user interface analysis techniques: comparison and contrast
    • John BE, Kieras DE. The GOMS family of user interface analysis techniques: comparison and contrast. ACM Trans Comput-Hum Interact 1996;3:320-51.
    • (1996) ACM Trans Comput-Hum Interact , vol.3 , pp. 320-351
    • John, B.E.1    Kieras, D.E.2
  • 39
    • 48949116379 scopus 로고    scopus 로고
    • Forecasting emergency department crowding: a discrete event simulation
    • Hoot NR, LeBlanc LJ, Jones I, et al. Forecasting emergency department crowding: a discrete event simulation. Ann Emerg Med 2008;52:116-25.
    • (2008) Ann Emerg Med , vol.52 , pp. 116-125
    • Hoot, N.R.1    LeBlanc, L.J.2    Jones, I.3
  • 40
    • 0033075593 scopus 로고    scopus 로고
    • Application of discrete-event simulation in health care clinics: a survey
    • Jun JB, Jacobson SH, Swisher JR. Application of discrete-event simulation in health care clinics: a survey. J Oper Res Soc 1999;50:109-23.
    • (1999) J Oper Res Soc , vol.50 , pp. 109-123
    • Jun, J.B.1    Jacobson, S.H.2    Swisher, J.R.3
  • 41
    • 33846867009 scopus 로고    scopus 로고
    • Simulation modelling in healthcare: reviewing legacies and investigating futures
    • Eldabi T, Paul RJ, Young T. Simulation modelling in healthcare: reviewing legacies and investigating futures. J Oper Res Soc 2007;58:262-70.
    • (2007) J Oper Res Soc , vol.58 , pp. 262-270
    • Eldabi, T.1    Paul, R.J.2    Young, T.3
  • 42
    • 84885889573 scopus 로고    scopus 로고
    • Agent-based simulation of emergency departments with patient diversion
    • Weerasinghe D, eds, Berlin: Springer
    • Laskowski M, Mukhi S. Agent-based simulation of emergency departments with patient diversion. In: Weerasinghe D, eds. Electronic Healthcare. Berlin: Springer, 2009, 25-37.
    • (2009) Electronic Healthcare , pp. 25-37
    • Laskowski, M.1    Mukhi, S.2
  • 43
    • 54949159396 scopus 로고    scopus 로고
    • Capacity of clinical pathwaysda strategic multi-level evaluation tool
    • Cardoen B, Demeulemeester E. Capacity of clinical pathwaysda strategic multi-level evaluation tool. J Med Syst 2008;32:443-52.
    • (2008) J Med Syst , vol.32 , pp. 443-452
    • Cardoen, B.1    Demeulemeester, E.2
  • 44
    • 77956096822 scopus 로고    scopus 로고
    • Patient handovers within the hospital: translating knowledge from motor racing to healthcare
    • Catchpole K, Sellers R, Goldman A, et al. Patient handovers within the hospital: translating knowledge from motor racing to healthcare. Qual Saf Health Care 2010;19:318-22.
    • (2010) Qual Saf Health Care , vol.19 , pp. 318-322
    • Catchpole, K.1    Sellers, R.2    Goldman, A.3
  • 45
    • 79958262632 scopus 로고    scopus 로고
    • NSW., Health, [Internet]., Correct Patient, Correct Procedure and Correct, Site
    • (accessed 20 Sep 2010)
    • NSW Health [Internet]. Correct Patient, Correct Procedure and Correct Site. 2007. http://www.health.nsw.gov.au/policies/pd/2007/PD2007_079.html (accessed 20 Sep 2010).
    • (2007)
  • 46
    • 85014101725 scopus 로고    scopus 로고
    • (accessed 20 Sep 2010), NSW., Health, [Internet]
    • NSW Health [Internet]. Hand Hygiene Policy. 2010. http://www.health.nsw.gov.au/policies/pd/2010/PD2010_058.html (accessed 20 Sep 2010).
    • (2010) Hand Hygiene Policy
  • 47
    • 78249272003 scopus 로고    scopus 로고
    • Safety through redundancy: a case study of in-hospital patient transfers
    • Ong M-S, Coiera E. Safety through redundancy: a case study of in-hospital patient transfers. Qual Saf Health Care 2010;19:-32.
    • (2010) Qual Saf Health Care , vol.19 , pp. 32
    • Ong, M.-S.1    Coiera, E.2
  • 48
    • 0001022016 scopus 로고    scopus 로고
    • Formal aspects of model validity and validation in system dynamics
    • Barlas Y. Formal aspects of model validity and validation in system dynamics. Syst Dyn Rev 1996;12:183-210.
    • (1996) Syst Dyn Rev , vol.12 , pp. 183-210
    • Barlas, Y.1
  • 49
    • 0347164816 scopus 로고    scopus 로고
    • Organisational sources of safety and danger: sociological contributions to the study of adverse events
    • West E. Organisational sources of safety and danger: sociological contributions to the study of adverse events. Qual Health Care 2000;9:120-6.
    • (2000) Qual Health Care , vol.9 , pp. 120-126
    • West, E.1
  • 50
    • 41549099615 scopus 로고    scopus 로고
    • Reducing diagnostic errors through effective communication: Harnessing the power of information technology
    • Singh H, Naik A, Rao R, et al. Reducing diagnostic errors through effective communication: Harnessing the power of information technology. J Gen Intern Med 2008;23:489-94.
    • (2008) J Gen Intern Med , vol.23 , pp. 489-494
    • Singh, H.1    Naik, A.2    Rao, R.3
  • 51
    • 0141834049 scopus 로고    scopus 로고
    • Human errors in medical practice: Systematic classification and reduction with automated information systems
    • Kopec D, Kabir MH, Reinharth D, et al. Human errors in medical practice: Systematic classification and reduction with automated information systems. J Med Syst 2003;27:297-313.
    • (2003) J Med Syst , vol.27 , pp. 297-313
    • Kopec, D.1    Kabir, M.H.2    Reinharth, D.3
  • 52
    • 0037495031 scopus 로고    scopus 로고
    • Improving safety with information technology
    • Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003;348:2526-34.
    • (2003) N Engl J Med , vol.348 , pp. 2526-2534
    • Bates, D.W.1    Gawande, A.A.2
  • 54
    • 1542327773 scopus 로고    scopus 로고
    • Some unintended consequences of information technology in health care: The nature of patient care information system-related errors
    • 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 Am Med Inform Assoc 2004;11:104-12.
    • (2004) J Am Med Inform Assoc , vol.11 , pp. 104-112
    • Ash, J.S.1    Berg, M.2    Coiera, E.3


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