Wenn das KIS Fehler macht: von Critical incidents und Adverse events im Alltag

Information and communication technologies have been widely distributed throughout the healthcare system during the past ten years. Process optimisations, increased efficiency and efficacy as well as improved patient safety have been the positive outcomes of this evolution. Negative outcomes exist as well: scaring reports on increased mortality due to badly implemented IT systems might be the top of the pyramid. However, publications addressing computer-related adverse events in healthcare are only scarce. As the risk of e-iatrogenesis rises, this publication presents outcomes of the CIRS database in our hospital, including 312 reports during 2011 with the clinical information system being mentioned most frequently. Additionally, a framework consisting of ten technical and ten sociotechnical archetypes (TST-20) associated with adverse events is proposed. By requesting, recording, classifying and publishing computer-related adverse events, we move ahead towards the era of evidence-based medical informatics.