A Visual Computer Interface Concept for Making

Error Reporting Useful at the Point of Care

Ranjit Singh, MA, MB, BChir (Cantab.), MBA; Wilson Pace, MD; Ashok Singh, MA, MB,
BChir (Cantab); Chester Fox, MD; Gurdev Singh, MScEng, PhD (Birm)

Abstract
Reports on errors can be a rich source for understanding their causes, cascades, and
consequences, leading to interventions for improvement. There are national and international
calls for the development of appropriate error reporting and taxonomy systems that are useful at
the point of care. The current momentum and urgency for these developments present an
opportunity to harness the benefits of computer visualization that helps structure and illustrate
the “story” of an error. This visualization process could help overcome the shortcomings of
current reporting methods and could aid in creating an unambiguous international error
taxonomy. We present a concept for a visual error reporting interface. The ambulatory care
domain is used for illustration. The system has the potential to provide a user friendly, efficient
means of reporting errors. Errors reported in this way would populate a “visual database,”
providing the ability to disseminate patient safety information in a straightforward, structured
format that will be useful to a variety of stakeholders.

Introduction
A huge chasm exists between the potential and actual quality of care delivered by the health care
industry. In the United States, this chasm appears to be consistently wide across the Nation and
the spectrum of care delivery venues. 1

Creation of a culture of safety is a critical first step for health care organizations that wish to
improve quality and safety. 2 One of the steps in developing a culture of safety is the recognition
by staff and clinicians of errors that occur on a regular basis. 3 One of the primary drivers to
achieve this recognition is error reporting. Reporting systems need to be safe (i.e., free from
blame), easy, and worthwhile. 4, 5 Error reports can be a rich source for uncovering errors, and
through further study, can lead to an understanding of causes, cascades, and consequences of
errors, in turn leading to the design of interventions for improvement.

Error reports represent the “tip of the iceberg,” as only a small fraction of errors are typically
reported, and the information contained in the reports is limited to what reporters perceive and
are willing to share. Other methods of analysis, which may be based on error reports, include
failure modes and effects analysis, root cause analysis, chart review, and direct observation.
These are needed to provide a more complete assessment of risks within an organization. Error

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reporting is nevertheless an important modality and should be seen as complementary to the
other approaches.

In the United States, the Patient Safety and Quality Improvement Act of 2005 6 was intended to
encourage and facilitate error reporting. The Act calls for the formation of Patient Safety
Organizations (PSOs) that can safely collect and analyze data on medical errors without the legal
risk of discovery. In conjunction with the president’s 2004 call for national implementation of
electronic medical records (EMRs) and the creation of the office of the National Coordinator for
Health Information Technology, PSOs will be asked to pool their deidentified data, which should
support the creation of searchable electronic databases of errors that are secure, involve low
medico-legal risk, and can be analyzed and used to develop systemic solutions to health care
safety problems. 7

The collation of error reports into central databases can be useful at two levels. First, and
currently the focus of most efforts, is the regional, national, or international level, which we shall
refer to as the “macro-system level.” These pooled databases have the potential to receive large
numbers of reports and, therefore, might be able to detect infrequent errors and track trends in
reporting frequencies over time. In addition, since a large number of providers will, it is hoped,
submit data, the publication of summary statistics will not compromise the confidentiality of
individual providers. In the United States, legislation will help protect these data from medico-
legal discovery.6

One difficulty with error analysis at the macro-system level is that the generalizations made
about national data might not apply (or, be perceived by individual physicians not to apply) to
individual practices or hospital floors. The Director of the Agency for Healthcare Research and
Quality (AHRQ) has emphasized that quality and safety information needs to be made useful at
the point of care to patients and health care providers. 8 Similarly, the United Kingdom’s House
of Commons Committee of Public Accounts, in its report “A safer place for patients: Learning to
improve patient safety,” calls for a unified and convenient form for reporting and a taxonomy
that encourages feedback on solutions to specific patient safety incidents. 9 Therefore, in addition
to macro-system level data, individual practices/health care sites and organizations need local
“micro-system level” information that is directly relevant to them and can be used internally to
drive safety improvement. Such information, reported internally for quality and safety
improvement purposes, potentially has more legitimacy in the eyes of local staff and clinicians in
any health care setting.

The overall purpose of our work is to develop and test a concept for a visual medical error
taxonomy, built on visual reporting, that can provide for both macro-system and micro-system
level needs. Figure 1 depicts the overall concept in which error reporting at the micro-system
level is used internally for safety improvement, as well as being fed seamlessly to a regional,
national, or international database that is used to study the epidemiology of errors and to generate
alerts. The purpose of this paper is to present the concept of visual reporting. Before presenting
this concept, it will be helpful to describe the framework of the error taxonomies that have to be
populated by the proposed visual reports.

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E

Figure 1. Overview of the concept for visual taxonomy and reporting. Adapted from Singh R, Pace W, Singh S, et
al. A concept for a visual computer interface to make error taxonomies useful at the point of primary care. Infomat
Prim Care 2007; 15:221-229.

Error Taxonomies
A number of error taxonomies have been and are being developed to organize and classify error
reports. The Institute of Medicine’s (IOM) report “Patient Safety: Achieving a New Standard for
Care” 10 calls for the development of an event taxonomy. The Joint Commission has proposed a
taxonomy 11 and is working with the World Health Organization (WHO) to establish a common
international system for classification. 12 The International Primary Care Patient Safety
Taxonomy Steering Committee has given itself the important and necessary task of developing
“a primary care taxonomy for patient safety, embedded in the International Classification of
Primary Care (ICPC-2) and in an episode of care structure, that can operate across settings and
vendors, and that maps to other standards and data structures.” 13

Current taxonomies are essentially alphanumeric codes that are used to classify and summarize
error data (whether at local, regional, national, or international levels) for various purposes
including:
• Communication of information about errors and their characteristics, including causative
factors, consequences, and severity (keeping in mind that error reporting alone might be
insufficient for fully addressing these issues).

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• Estimation of frequencies and trends of various error types.
• Identification of needs for safety improvement.

While such taxonomies have been used successfully in primary care and other settings, they have
some limitations:
• The coding systems are complex and prone to ambiguity.
• They do not readily meet the point-of-care needs of patients and health care providers to
understand, within their own unique micro-systems, the causes, cascades, and consequences
of the reported errors.
• They do not fully capture the “story.” By reducing an incident to a series of codes, the flavor
of the event is lost. It is the “story” that has the greatest potential to contribute to safety
improvements.4, 14
• They often differ in the way they define, count, and track events, and they use different
terms, data, coding methods, and analysis. This makes it difficult to compare data that have
been collected or coded using different taxonomies.

According to the IOM,10 a comprehensive National Health Information Infrastructure must

provide information flow across three dimensions: (1) personal health, to support individuals in
their own wellness and health decisionmaking; (2) health care providers, to ensure access to
clinical decision support systems; and (3) public health, to address and track public health
concerns and health education campaigns. Items 1 and 2 correspond to the micro-system level,
while item 3 is at the macro-system level. Use of a consistent error taxonomy across these levels
is imperative.

The need for a consistent error taxonomy at both micro- and macro-system levels presents an
opportunity to harness the benefits of computer visualization. Our experience with visualization
suggests that this will help create crosswalks between disparate taxonomies. A very important
feature of visualization is that it can help structure and illustrate the “story” of an error or event.
The proposed visual taxonomy is coded at four main levels, corresponding to the structure of the
visual models: 15
• Health care domain.
• Process.
• Sub-process.
• Entity/interaction.

A reported event can consist of one or more errors, together with causes and consequences. Each
of these is coded at the above four levels.

Visualization
We take the view that visualization is a universal tool that furnishes a natural common
“language.” For instance, it is used effectively for international road signs. It respects and aids
inductive (as opposed to linear) perception and decisionmaking that is the natural way that the
human brain works. 16 It can provide:

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• A fast path to fully engaging the minds of individuals and their teams, including patients.
• Insight into causes, cascades, and consequences of errors.
• A common vision for teamwork, with the potential for improved outcomes.
• An aid for coping with the complexities, fragmentation, and decentralization of the health
care system.2
• An aid for mapping across different taxonomies and data structures.16

Applying a systems engineering/management approach, we have developed visual models at the

macro-system and micro-system levels. 17

Macro-System Model
The macro-system model is a high level view (Figure 2) of the health care system. The processes
of care are represented by the radials. These processes are recognized to occur in a cyclical
fashion, as shown by the clockwise progression around the circle from Assessment to Plan to
Implementation, Feedback, Review & Learn and back to Assessment again.17

These processes in the cycle of care take place in various domains that are depicted by concentric
circles. The increasing sizes of the circles depict the enlarging involvement of the system,
starting from the patient level at the center to the international health authority level on the
outside. The innermost circle represents the patient in his/her own domain (i.e.,
home/community) and recognizes that this is where most health care actually occurs.
International health authorities (e.g., World Health Organization), depicted by the outermost
circles, play an important role in devising public health policies that can affect management of
patients at all points within the system. Office-based primary care is represented by circle 1.
Depending on the system under study, circle 2 might represent the emergency room, and circle 3
might represent the hospital inpatient setting, etc.

The main purpose of this macro-system model is to understand a patient’s care in the context of
the overall health care system, especially with respect to errors and opportunities for errors,
including errors that may occur in transitions between different parts of the system. This is best
illustrated through the use of an example. Suppose a 59-year-old male patient with a long history
of hypertension arrives at his primary physician’s office with intermittent atypical chest pain of 2
days’ duration. He is currently having retrosternal burning chest pain.

The scenario therefore begins at point 1A in Figure 2, with the patient in the office setting being
assessed by the physician. Based on the history and physical exam, the physician decides to
order sublingual nitroglycerine and an EKG; this is the Plan (point 1P). The order is conveyed to
the nurse, who gives the patient nitroglycerine, completes the EKG (Implements the Plan,
point 1I). The nurse presents the printed EKG to the physician and informs him/her that the
patient’s pain did not improve despite three doses of nitroglycerine (this is the Feedback, point
1F). The physician reviews the EKG (point 1R) and notices some T-wave inversion in the
inferior leads. The physician goes back into the room to reassess the patient (back to point 1A)
and finds that the patient’s chest pain is getting worse (it has been ongoing for 30 minutes), and
the patient is diaphoretic. Now the physician decides (point 1P) to transfer the patient to the
emergency room for evaluation to rule out acute coronary syndrome (ACS).

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Figure 2. Macro-system model of health care. Adapted from Singh R, Singh A, Fox C, et al, Computer visualization
of patient safety in primary care: A systems approach adapted from management science and engineering. Informat
Prim Care. 2005; 13: 135-144.

The patient makes a transition from the office to the emergency room, shown in Figure 2 by the
dotted line from point 1P to point 2I. In the emergency room (circle no. 2), similar cycle(s) of
care occur, starting with Assessment (point 2A). The patient is treated in the emergency room
according to their “rule out ACS” protocol and discharged home after “ruling out.”

The next day, the primary physician receives a copy of the emergency room record (transition
back to point 1F) and reviews it (point 1R). He/she is pleased to learn that the patient did well
and has been diagnosed with “probable GERD” after responding well to a “GI cocktail” in the
emergency room. As the physician reflects on what happened to the patient (also part of the
Review & Learn process, point 1R), he/she realizes that he/she missed the opportunity to give
the patient aspirin in the office (which he/she should have done, since the patient was not on
aspirin, and he/she was entertaining the diagnosis of ACS). Further, the physician considers
whether he/she and his/her colleagues should improve their systems for dealing with chest pain
patients, perhaps by using a written protocol for managing chest pain in the office. The following
week, the patient returns for followup with the primary physician (point 1A) and the cycle
continues.

Thus, cycles of care can occur multiple times in one setting and/or involve transitions between
settings. The macro-level view aims to provide the “big picture,” so as to facilitate understanding
of the processes of care in different interrelated parts of the system and transitions between these
parts, helping the user understand interdependencies and the need for information flow.

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Micro-System Models
The micro-system models are close-up views of the system; each may represent one or more
points within the macro-system model. For example, one might devise a micro-system model for
a specific domain within the macro-system or for a specific process within a domain. These
models show how the various entities/agents in the micro-system interact. The level of detail
represented in a micro-model depends on the purpose for which it is used.

Figure 3 depicts a micro-system model for medication management in ambulatory settings. It

shows activities in the office, pharmacy, home, laboratory, imaging/radiology facility, and third

party payer and the interactions within and between these. Each interaction is shown as an arrow.
Errors or safety problems can originate at any one point or at multiple points in the system.

The macro-system and micro-system diagrams are computerized and contain “hyperlinks” that
facilitate hierarchical linkage between models and can be used for dynamic data links within
databases. For example, any point on the micro-system model can be linked electronically to a
table containing relevant data about errors that are known to occur at that point in the system,

Figure 3. Micro-system model of medication management.

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with details of frequency and consequences of these errors and corrective action recommended
or used. These macro- and micro-system models can also provide various other functions that we
have described elsewhere.17

A Visual Error Reporting Tool

Figure 4 is an example of how a visual reporting tool could be used, based on the same micro-
system model shown in Figure 3. To report an error, the user would first describe the patient’s
demographic details and enter other information deemed appropriate, such as their job
designation, circumstances in which they discovered the error, etc. Then they would commence
entering details of the error using the visual interface.

In this case, the error is that the primary doctor (who is reporting this error) refilled the wrong
dose of a blood pressure medication by phone. The patient is a 76-year-old female with type 2
diabetes mellitus, hypertension, and coronary artery disease (CAD). She sees her primary doctor
every 3 months and is on various appropriate medications, including quinapril 10 mg daily for
hypertension. She also sees a cardiologist annually for CAD followup and management. At
today’s visit to the primary doctor’s office, the doctor notices that her blood pressure is above
goal at 147/90, while it had been well controlled at previous visits (including the most recent
visit 3 months ago). Therefore, he/she inquires as to the patient’s compliance with the
medication, to which the patient replies “my pressure’s probably up because you cut down my
medication dose last time.” The doctor reviews the chart and finds no documented change in any
blood pressure medication. He/she inquires further and discovers that at the patient’s previous
visit to the cardiologist (8 months earlier), the cardiologist had noted elevated blood pressure and
increased the dose of quinapril from 10 mg to 20 mg daily and also prescribed a 6-month supply.
Then, 2 months ago, when the patient was running out of quinapril, she called her primary
doctor’s office for a refill. The doctor reviewed the chart and instructed the nurse to phone in a
prescription for quinapril 10 mg daily, since this was the dose documented in the patient’s chart.
There was no consult letter in the chart from her cardiologist. The patient had seen the primary
doctor twice since the cardiology visit but apparently had not mentioned the dose change.

Panel 1 of Figure 4 shows how the doctor would indicate the location of the error, which in this
case is in the communication (via telephone) between the doctor’s office and the pharmacy.
Next, in Panel 2, when presented with a list of possible errors in this step, the reporter picks the
relevant item from the list, which in this case was “Wrong dose.” Next, the user chooses to
describe the contributing factors. As mentioned earlier, one of these was that the chart did not
contain any information from the cardiologist regarding the dose change. The user therefore
clicks on the chart and chooses the appropriate item from the list, as shown in Panels 3 and 4.
Another contributor was that the patient did not inform the primary doctor about the dosage
adjustment; this can be entered in the same fashion.

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 Click where the error occurred From the list, select the Error that occurred

1 Office Pharmacy
2 Office Pharmacy
Chart Chart

Phone/Fax Phone/Fax
Nurse Nurse
Pharmacist Pharmacist
Select Error:
Recept. Recept.
Wrong patient
Patient/ Script
Patient/ Patient/ Wrong medication
Script
Patient/
Doc Caregiver Caregiver Doc Caregiver Wrong dose Caregiver
Wrong frequency
Wrong route
Wrong # of doses
Patient/ Click Here Patient/
Caregiver Medication Wrong #of
Caregiver refills
Medication Click on
Lab (this is Lab this
Home where the Home error
error
occurred)
Errors Errors
Contributors Consequences Severity Story Contributors Consequences Severity Story
Cascade Cascade

Contributing factors for Error: Wrong dose Contributing factors for Error: Wrong dose

3 Chart
Click on the place where a Contributor occurred

Office Pharmacy
4 Chart
Select the Contributor from the list

Office Pharmacy

Phone/Fax Phone/Fax
Nurse Nurse
Pharmacist Pharmacist
Select Contributor:
Missing/inaccurate information: Recept.
Recept. Script
Patient/ Script Weight Patient/ Patient/
Patient/
Doc Caregiver Allergies
Doc Caregiver Caregiver
Caregiver
Prescription meds
OTC meds
Past medical history / Problem list
Lab values
Click here Patient/ Consult reports Patient/
Click on
Medication Medication
first Caregiver Phone messages Caregiver
this
Lab Lab Home
Home Poor chart design: contributor
Problem list
Medication list
Errors Allergy list Errors
Contributors Consequences Severity Story ….
Contributors Consequences Severity Story
Cascade Cascade

Consequences of Error: Wrong dose Consequences of Error: Wrong dose

Click on the place where a Consequence occurred Select the Consequence from the list

5 Chart Office Pharmacy 6 Chart Office Pharmacy

Phone/Fax Phone/Fax
Nurse Nurse
Pharmacist Pharmacist

Recept. Recept.
Patient/ Script Patient/ Script
Patient/ Patient/
Doc Caregiver Caregiver Doc Caregiver Caregiver

Patient/ Click here Patient/Select Consequence:

Caregiver Medication (where the Click on Caregiver Medication
Missed medication
Lab Home consequence Lab this Home
Under-medication
occurred) consequence
Over-medication
Errors Errors Medication side effects
Contributors Consequences Severity Story Contributors Consequences …. Severity Story
Cascade Cascade
G and R Singh 2001 G and R Singh 2001

Consequences of Error: Wrong dose Consequences of Error: Wrong dose

Click on the Severity level Please give a brief story
7 Chart Office
Severity Level
1. ................
Pharmacy
8 Chart Office Pharmacy
2. ................ Severity is selected
Phone/Fax Phone/Fax
Nurse 3. ................ from a scale like this Nurse
Pharmacist Pharmacist
4. ................
The story can be typed into a box like this one
Recept. Recept.
Patient/ Script Script
Patient/ Patient/
………… Patient/
Doc Caregiver Caregiver Doc Caregiver Caregiver

Click here
Patient/ to enter the Patient/
Caregiver Medication Caregiver Medication
Lab ‘Story’ Lab
Home …. Home
Errors Errors
Contributors Consequences Severity Story Contributors Consequences Severity Story
Cascade Cascade
G and R Singh 2001 G and R Singh 2001

Figure 4. Example of interactive error reporting.

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Similarly, the user is prompted to indicate the location and nature of any consequences. In this
case (Panels 5 and 6), the patient was under-medicated. Finally, the severity of the error can be
elicited, usually on a scale, as indicated in Panel 7, and the user types a brief narrative
description of the event to add any other details and help to eliminate any ambiguities (Panel 8).

The various lists, hyperlinked to the entities and their interactions, are designed to help reduce
emotive and cognitive biases in perceptions and reporting.

Discussion
We have proposed a novel approach, based on computerized visual models of the health care
system, to facilitate the reporting, summarizing, and dissemination of information about medical
errors in primary care. The purpose is to make information about medical errors useful both at
the practice level and at the policymaking level.

The ability to view a macro- or micro-system diagram together with error frequency information
can be valuable in helping decisionmakers at various levels in the health care system identify and
prioritize areas for system improvement. Similarly, the ability to summarize a single event—
including errors, contributing factors, and consequences—in a clear visual format would appear
to provide some advantages when compared to a list of codes. It should be noted that in any
reporting system, reports are submitted by human beings who have their own unique viewpoints
and past experiences that color their perception of incidents. For example, perceptions of
contributing factors will likely vary among reporters for the same incident.

Our hypothesis (as yet untested) is that a visual format could help overcome this issue because
the process of reporting involves looking at and interacting with system models. These remind
the reporter of the processes that are in place, his/her role in them, the problems that can occur,
contributors that might be present, and consequences that can occur, thereby improving
situational awareness, 18 as well as aiding narration of the “story.” In other words, the visual
models and associated drop-down lists have the potential to help create a common vision of the
system. Furthermore, we suggest that a visual format can facilitate information sharing with team
members and other stakeholders (including patients and families) and has the potential to
enhance the understanding of events, thus facilitating the development of appropriate preventive
strategies.

Error reporting using a visual format would require appropriate staff training, probably more so
than for a simple paper-based reporting tool. Staff would need to be familiarized with the visual
models and the interface. However, some of the potential benefits outlined above might justify
such an up-front effort.

Another benefit, important from a practical perspective, is the fact that this visual reporting
approach allows the user to code the error while reporting it. This contrasts with conventional
reporting systems using existing taxonomies, which require considerable time and effort to
dissect written error reports and code them. Individual practices wishing to collect and
understand local error data generally cannot afford the time and effort required to manually code
errors using alpha-numeric taxonomies, nor are they likely to have the expertise to do so.

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Further work is needed to fully operationalize the concepts described here and to evaluate the
usability of the visual interface and its potential benefits. In order for the process to be used
across health care settings and internationally, it would be necessary to create visual diagrams of
other systems. We are beginning to create standardized icons for the whole range of entities in
the various settings of the health care system. These would enable interactive creation of micro-
system models (potentially by end-users) for any setting.

Figure 5 shows two examples of micro-system models developed for falls and postoperative pain
management in a hospital setting. In addition, to facilitate use in a wide variety of settings, this
kind of reporting tool should be accessible directly from within electronic medical record
systems and should be able to import patient data directly from these records. A recent study 19 in
the domain of operating theaters demonstrated that integration of an incident reporting system
into an electronic patient record significantly increased the number of incidents reported.

While tracking rates of errors over time or comparing rates among different institutions or
regions are commonly perceived aims of error reporting systems, caution is needed in
interpreting such data because of the problem of underreporting. According to IOM estimates,
only about 5 percent of known errors are reported.2 Therefore, differences in rates of errors
reported over time or among institutions do not necessarily reflect true differences in rates of
errors but may merely represent differences in reporting behavior.

Similarly, and perhaps even more importantly, those errors that are reported most frequently are
not necessarily the errors that occur most frequently. They are merely the ones that reporters feel
more comfortable reporting. 20 It is hoped that creating more user-friendly and intuitive reporting
tools, such as the one described here, will help increase reporting rates and so, provide more
opportunities to learn. However, this needs to be done in concert with changes in organizational
culture 21 that encourage reporting and learning from errors and discourage blame and
punishment for errors that are due to systemic problems. In other words, a shift from the
prevailing culture of blame to a culture of safety is called for.

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 Knowledge and Info

The Post-Operative TEAM

RN

Tech.
Resident
pharm
Support
Attending

Consultant
psychologist
Results of Diagnostic Studies
LAB, X-Ray, MRI, CAT
Vital signs-including pain
Chart

Policies
Protocols
Guidelines

Physio Nutrition/
Therapist administration

Macro-Link

Figure 5. Examples of micro-system models for inpatient falls (top) and for postoperative pain management
(bottom). Adapted from Singh R, Naughton B, Anderson D, et al. Building self-empowered teams for improving
safety in postoperative pain management. In press.

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Author Affiliations
State University of New York at Buffalo (Dr. R. Singh, Dr. Fox, Dr. G. Singh); American
Academy of Family Physicians National Research Network and University of Colorado
(Dr. Pace); Niagara Family Medicine Associates (Dr. A. Singh).

Address correspondence to: Ranjit Singh, MA, MB, BChir (Cantab), MBA, Associate Director,
Patient Safety Research Center, Primary Care Research Institute, State University of New York
at Buffalo, UB Clinical Center - Rm CC155, 62 Grider Street. Buffalo NY 14215;
telephone: 716-898-5544; fax: 716-898-3536; e-mail: rs10@[Link]

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