Information and Knowledge Management using ArcGIS ModelBuilder

Mohamad Norzamani Sahroni and Maryati Mohd Yusof
attributed to lack of understanding of the evaluation process (Tuten 2009) on the overall medical error
management (Donabedian and Bashshur 2003, Hakimzada et al. 2008, Patel and Kane-Gill 2010). It
also includes lack of the definition and the classification on type of error occurred (Zapf et al. 1992,
Vozikis 2009, Habraken and Van Der Schaaf 2010) and limited error identification (Esimai 2005,
Koppel et al. 2008, Garfield et al. 2009) of medical processes. Furthermore, it may also contribute to
the difficulty to perform evaluation process (Mohd Yusof 2007) due to the complexity of medical
process (Hübner-Bloder and Ammenwerth 2009). So, evaluation of medical error should be allencompassing
in its specific setting if not entirely in the whole complex health care systems in order to
get holistic understanding on the occurrence of error, and how well HIS is integrated and supported
medical processes (Garcia-Smith 2007, Hübner-Bloder and Ammenwerth 2009). Thus, with a clear
definition and classification type of error in HIS, it is expected to understand the extent of HIS
outcome in reducing error as well as nurturing new error in medical process.
3.1.1 Definition of error
Various definitions of error have been applied towards patient safety but there was lack of standard
definitions and taxonomy of medical errors (Vozikis 2009) especially to have a definition of error that
associates with HIS. This situation bring more issues to this area of study that lead to unclear and
uniform of medical error reporting. Error in general is defined as “failure of planned actions to achieve
their desired goal” (Reason 1995). Cosby (2003) defines error as “a failure to meet some realistic
expectation (an action, process, diagnosis, or endpoint. Therefore, this research context will define
error in HIS is referred to the failure of HIS to attain its desired goal in reducing error and/or
preventing new error to occur in medical process because of following wrong or incomplete planned
action or deviating from its original planned action. Failure in the given definition is referring to the
partial failure of HIS instead of total failure where there might be certain goal is not attained or HIS is
produced undesirable outcome (Heeks 2006) such as new error.
3.1.2 Type of error
Literature shows that there are lacks of uniform classification on type of medical error (Vozikis 2009).
This may be resulting of unclear type of error reduces or nurtures in HIS. Table 1 summarizes
different classification on type of medical error.
According to Leape (1993), type of medical error can be viewed from four types of diagnostic,
treatment, preventive and other types. This kind of classification is based on general medical
management process where the sub type of error might be changed according to setting and context.
Whilst (Koppel et al. 2005) used themes to describe its two types of error; information error and HIS
interface flaws. Koppel et al. study is based on the identified 22 previously unexplored medicationerror
in CPOE.
Meanwhile Reason’s (1995) Theory of Human Error proposed that medical error is divided into two
types; slips and laps, and mistakes. Slips and lapse means the failure of the execution of planned
action and mistake is the failure of the plan of intended goal even though the execution is faultless.
Besides, Zhang et al. (2004) also proposed two major type cognitive taxonomy of medical error due to
human factor associates with technology; mistakes and slips. Mistake is an error occurs because of
the person has incorrect or incomplete knowledge to perform certain task. Meanwhile if error occurs
with the person has correct knowledge to perform certain task, it was a slip. Each type then is divided
into execution and evaluation where evaluation is the result of the action of executions. These types
are based on the combination theories of Human Error and Norman’s Human Action. Further both
Reason (1995) and Zhang et al. (2004) discussed important aspect of human error as well as
contributing factor to human error. Both Reason’s (1995) and Zhang et al. (2004) classification looking
consistent to be applied in different setting and context of evaluation in health care. In addition, both
studies also highlighted factors associated to the occurrences of medical error. However, the limitation
lingers on the cognitive of human factors.
However, the classification type of error provided by Zapf et al. (1992) is much easier to apply. Zapf et
al. identified functionality to represent technical error, usability to represent human error that
associates with systems, interaction to represent individual communication and organization process,
and inefficiency that also due to human factor because of lack of knowledge to perform optimal action
path or due to habit. These types of error represent comprehensive approach to evaluation.