Analysis of General Event Types and Contributing Factors in Patient Safety System Data

Abstract

Patient safety event reporting systems (PSRS) aim to identify safety hazards by encouraging hospital staff to report adverse events, errors, and potential errors in the healthcare system. PSRS collect different information regarding a safety event such as contributing factors and general event types. Users select contributing factors and general event types of a safety incident from predefined lists; therefore, most frequent general event types and contributing factors are commonly recorded together. Contributing factors are often related to the leading cause of an unsafe condition; therefore, identifying contributing factors can help with detecting and mitigating safety issues. In this study, we identified the general event types and contributing factors which were frequently recorded together. We calculated point-wise mutual information (PMI) between each pair to find the association between a contributing factor and a general event type. Our analysis demonstrated strong association between general event type and contributing factors which were most frequently recorded together. Fall and lost/impaired balance (PMI=15.12), skin/tissue and friction/shear (PMI=14.32), and blood bank and patient/sample incorrectly identified (PMI=13.78) were the three pairs of general event type and contributing factors which presented strong association.