Challenges to Real-Time Decision Support in Health Care

Abstract

This article describes challenges in the design and development of a decision support system for trauma patient resuscitation that is used to encourage consistency and reduce error rates. The Trauma Reception and Resuscitation Project links real-time, computer-generated prompts from best practice algorithms via visual and auditory displays. Its functionality is now being tested. Evaluation of this decision support approach can employ patient chart review or observation, but we describe an approach that measures the process of care by video audit. Key process problems in trauma management (e.g., errors of omission, commission, and misprioritization) are identified. The video record provides a framework for learning and feedback. Future testing and development of this system will include a randomized clinical trial and technology enhancement. Introduction The development, testing, and validation of a real-time decision support system for use during trauma patient reception and resuscitation present many challenges. The decision support system described in this article is part of the Trauma Reception and Resuscitation (TR & R) Project at The Alfred Hospital and Swinburne University of Technology in Melbourne, Australia. The hypothesis that inconsistency and medical errors can be reduced by use of a decision support tool is currently being tested in a randomized clinical trial. The TR & R Project concentrates on the first 30 minutes of trauma patients’ hospital reception and resuscitation. The types and causes of errors that occur in the complex dynamic medical domain of a trauma center and the need for decision support are described. An interdisciplinary approach to decision support development is outlined. Future output, testing, and development of the TR & R Project are described Safety and Errors in Emergency Medical Care Cognitive errors during emergency care are a significant contributor to patient harm. Approximately half the litigation brought against emergency physicians arises from delayed or missed diagnoses. Traditionally, cognitive errors are classified into those of omission and commission. Omission errors are, in hindsight, events that occur through the natural progression of a disease, and they are noted as a tendency toward inaction. In a total error of omission, nothing has been done to achieve a goal; in a partial omission, some action has been taken. Errors of omission are more difficult to detect than those that can be attributed directly to the action of a physician. In contrast, errors of commission result in harm to the patient that, in hindsight, could have been prevented by different or no interventions. Such errors are more