Using Publicly Available Recall and Safety Alert Reports for Learning from Technology-Induced Error.

Abstract

Information technologies have the potential to increase the safety of healthcare and advance safety science. However, it is now well known that health information systems may also inadvertently introduce new forms of error known as technology-induced error. Such errors may be difficult to detect as they may only appear under conditions of system use in real healthcare settings. In this paper, the authors explore the use and assessment of recall and safety alerts for both identifying and learning from technology-induced error. Publically available safety and recall reports from Canada were analyzed to identify opportunities to improve organizational learning from technology-induced errors. Although a range of error types were identified, it was found that none of the reports provided detailed information about the underlying technical circumstances that led to the need for a recall. Implications for future reporting systems to support learning from technology-induced error are discussed.