Abstract：
Complex socio-technical health information systems (HIS) issues can create new error risks. Therefore, we evaluated the management of HIS-related errors using the proposed human, organization, process, and technology-fit framework to identify the lessons learned. Qualitative case study methodology through observation, interview, and document analysis was conducted at a 1000-bed Japanese specialist teaching hospital. Effective management of HIS-related errors was attributable to many socio-technical factors including continuous improvement, safety culture, strong management and leadership, effective communication, preventive and corrective mechanisms, an incident reporting system, and closed feedback loops. Enablers of medication errors include system sophistication and process factors like workarounds, variance, clinical workload, slips and mistakes, and miscommunication. The case management effectiveness in handling the HIS-related errors can guide other clinical settings. The potential of HIS to minimize errors can be achieved through continual, systematic, and structured evaluation. The case study validated the applicability of the proposed evaluation framework that can be applied flexibly according to study contexts to inform HIS stakeholders in decision-making. The comprehensive and specific measures of the proposed framework and approach can be a useful guide for evaluating complex HIS-related errors. Leaner and fitter socio-technical components of HIS can yield safer system use.
摘要：
复杂的社会技术卫生信息系统（HIS）问题可能会产生新的错误风险。因此,我们使用拟议的人评估了HIS相关错误的管理，组织,process,和适合技术的框架，以确定吸取的教训。通过观察定性案例研究方法，采访,文件分析是在一家拥有1000张床位的日本专科教学医院进行的。有效管理HIS相关错误可归因于许多社会技术因素，包括持续改进，安全文化,强有力的管理和领导，有效沟通,预防和纠正机制，事件报告系统,和封闭的反馈回路。药物错误的促成因素包括系统复杂性和过程因素，如变通办法，方差，临床工作量，失误和错误,和误解。病例管理在处理HIS相关错误方面的有效性可以指导其他临床设置。HIS最小化错误的潜力可以通过连续的，系统，和结构化评估。案例研究验证了拟议评估框架的适用性，该框架可以根据研究背景灵活应用，以告知HIS利益相关者决策。所提出的框架和方法的全面和具体的措施可以成为评估复杂的HIS相关错误的有用指南。HIS的更精简和更适合的社会技术组件可以产生更安全的系统使用。
