Improving Patient Safety Through Health Care Incident Reporting, Analysis, and Process Change Systems
Bibliographic record
Abstract
Every year, tens of thousands of patients in North America die from preventable errors. Incident reporting and learning provide a means of decreasing this number, but due to several barriers, these systems are not currently reaching their full potential in health care. The goal of this study is to improve patient safety by designing strategies to advance incident learning in health care. A literature review was conducted to gather details about health care, aviation, and nuclear power incident learning systems. This information was used to identify areas for improvement in health care’s incident learning processes and extract potential strategies for improvement. The suggested strategies to be developed in this research could be followed by administrators who are making crucial decisions pertaining to the incident learning process. This should help create more effective systems, and in turn, improve patient safety.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.043 | 0.102 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.010 | 0.006 |
| Science and technology studies | 0.002 | 0.001 |
| Scholarly communication | 0.007 | 0.008 |
| Open science | 0.003 | 0.003 |
| Research integrity | 0.001 | 0.002 |
| Insufficient payload (model declined to judge) | 0.002 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".