A Root Cause Analysis Interface for Error Reporting

摘要

We describe a web-based interface that facilitates entering and analyzing medical errors. It uses an interactive causal tree-building component. The interactive component allows a user to build a causal tree with any number of events and antecedents. This replaces a form-based approach that is limited to a predetermined number of events and antecedents. After the causal tree is completed, the user can save the tree to a database. Causal trees can be retrieved and rebuilt as well. We developed an algorithm that, given a data bank of reported errors, will help detect similar events. This facilitates recognizing patterns of errors.