The root cause analysis of sentinel events and medical errors is a complicated business. Oftentimes it is not even clear whether a clinician or the system has failed. To help figure out who or what is responsible for clinical mistakes, Valeria Donati, a graduate student in interactive design at University of Venice, created a specialty computer table for clinicians and administrators to use to analyze medical errors. The design, borne out of her graduate thesis, is intended to promote collaboration and openness, while facilitating a more natural interaction with electronic clinical data.
Here’s what Ms. Donati tells Medgadget:
This project aims to avoid errors in the future and to make people less defensive during the clinical audit, which is a meeting organized by doctors, nurses and technical staff to analyze and prevent medical mistakes.
With Tondo the clinical staff can analyze day by day the history of a patient during his/her hospitalization and look all the exams, radiographies, blood test, etc made to the patient to discuss together them and to find where and when the error happened.
With the software included in the table physicians can save active and latent errors in a dedicate form. The active errors have been made by person. Latent errors are also called ‘systemic errors’ and they are often hidden behind an active one. The clinical audit is one of the main strategies used to analyze and prevent clinical mistakes in the hospital. Tondo, through its intuitive and easy to use interface aims to analyze the whole history of a person and to plan concretely how to avoid errors in the future. My project was made with the scientific support of the clinical risk center of Tuscany.
Project page: Tondo…