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Human patient simulation has been widely adopted in healthcare education despite little research supporting its efficacy. The debriefing process is central to simulation education, yet alternative evaluation methods to support providing optimal feedback to students have not been well explored. Eye tracking technology is an innovative method for providing objective evaluative feedback to students after a simulation experience. The purpose of this study was to compare 3 forms of simulation-based student feedback (verbal debrief only, eye tracking only, and combined verbal debrief and eye tracking) to determine the most effective method for improving student knowledge and performance.An experimental study using a pretest-posttest design was used to compare the effectiveness of 3 types of feedback. The subjects were senior baccalaureate nursing students in their final semester enrolled at a large university in the northeast United States. Students were randomly assigned to 1 of the 3 intervention groups.All groups performed better in the posttest evaluation than in the pretest. Certain safety practices improved significantly in the eye tracking-only group. These criteria were those that required an auditory and visual comparison of 2 artifacts such as "Compares patient stated name with name on ID band."Eye tracking offers a unique opportunity to provide students with objective data about their behaviors during simulation experiences, particularly related to safety practices that involve the comparison of patient stated data to an artifact such as an ID band. Despite the limitations of current eye tracking technology, there is significant potential for the use of this technology as a method for the study and evaluation of patient safety practices.

Patient identification errors are one of the major causes of medication errors. Most medication error studies to date have focused on reporting patient misidentification statistics from case studies, on classifying types of patient identification errors, or on evaluating the impact of technology on the patient identification process, but few have proposed specific strategies or guidelines to decrease patient identification errors. Our study makes three key contributions to the patient identification literature. To better understand the verification of patient identifiers (VPI) process, we first formalize the requirements for this process based on the Joint Commission's national patient safety guidelines. Second, we show the implications of these requirements by applying them to artifacts typically used in medication administration (e.g., patient's statements about their identity, patient's identification band, medication label, and medication order). Third, we evaluate whether nurses comply with these req...

Background: Comorbidities adversely impact heart failure (HF) outcomes. Telehealth can assist healthcare providers, especially nurses, in guiding their patients to follow the HF regimen. However, factors, including comorbidity patterns, that act in combination with telehealth to reduce home care nursing utilization are still unclear. Purpose: The purpose of this article was to examine the association of the comorbidity characteristics of HF patients with nursing utilization along with withdrawal from telehealth service during an episode of teleYhome care. Methodology: A descriptive, correlational study design using retrospective chart review was used. The sample comprised Medicare patients admitted to a New England home care agency who had HF as a diagnosis and had used telehealth from 2008 to 2010. The electronic documentation at the home care agency served as the data source, which included Outcome and Assessment Information Set data of patients with HF. Logistic and multiple regression analyses were used to analyze data. Results: The sample consisted of 403 participants, of whom 70% were older than 75 years, 55% were female, and 94% were white. Comorbidities averaged 5.19 (SD, 1.92), ranging from 1 to 11, and nearly 40% of the participants had 5 or more comorbidities. The mean (SD) nursing contacts in the sample was 9.9 (4.7), ranging from 1 to 26, and 52 (12.7%) patients withdrew from telehealth service. For patients with HF on telehealth, comorbidity characteristics of anemia, anxiety, musculoskeletal, and depression were significantly associated with nursing utilization patterns, and renal failure, cancer, and depression comorbidities were significantly associated with withdrawal from telehealth service. Clinical Implications: Knowledge of the association of comorbidity characteristics with the home care service utilization patterns of patients with HF on telehealth can assist the home health nurse to develop a tailored care plan that attains optimal patient outcomes. Knowledge of such associations would also focus home care resources, avoiding redundancy of resource utilization in this era of strained healthcare resources.

Introduction Eye tracking, used to evaluate a clinician's eye movements, is an example of an existing technology being used in novel ways by patient safety researchers in the simulated setting. The use of eye-tracking technology has the potential to augment current teaching, evaluation, and research methods in simulated settings by using this quantitative, objective data to better understand why an individual performed as he or she did on a simulated or naturalistic task. Methods Selected literature was reviewed with the purpose of explicating how eye tracking can be used by researchers and educators to evaluate error-prone processes. The literature reviewed was obtained by querying the databases PubMed, CINHAL, and Google Scholar using the key words eye tracking, patient safety, and medical errors from 2005 through 2015.An introduction to the use of eye tracking, including both theoretical underpinnings and technological considerations, is presented. In addition, examples of how eye tracking has been used in research studies conducted in both simulated and naturalistic settings are provided. Conclusions The use of eye-tracking technology to capture the eye movements of novice and expert clinicians has provided new insight into behaviors associated with the identification of medical errors. The study of novices' and experts' eye movements provides data about clinician performance not possible with existing evaluation methods such as direct observation, verbal reports, and thinking out loud. The use of eye tracking to capture the behaviors of experts can lead to the development of training protocols to guide the education of students and novice practitioners. Eye-tracking technology clearly has the potential to transform the way clinical simulation is used to improve patient safety practices.

Using observation, eye tracking, and clinical simulation with embedded errors, we studied the impact of bar-code verification on error identification and recovery during medication administration. Data supported that bar-code verification may reduce but does not eliminate patient identification (ID) and medication errors during clinical simulation of medication administration.

The objective of this study is to demonstrate the effectiveness of visualizations for exploring one error-prone health care process: nurses verifying patients’ identities during the medication administration process. We employed three types of process visualizations (i.e., Markov chains, sparklines, and timeline belt visualizations) to explore process execution data from an experiment wherein nurse participants ( N = 20) administered medications to three patients in a simulated clinical setting. One patient had an embedded error, with the medication being incorrect for the patient. The visualizations allowed us to view aggregate and individual-level process execution data, providing insights into the orders in which participants completed process steps. Although we used eye tracking videos, the system developed in this study can automatically generate visualizations using large process execution data sets produced from an array of sources, including observations, sensors, and health IT audit trails. In this article, we demonstrate that the visualizations provide insights complementary to quantitative measures regarding what process steps participants likely used to identify errors, with the visualizations requiring less work to produce. Therefore, the visualizations may be an effective means for efficiently comparing sets of process execution data (e.g., different individuals completing a process, pre– and post–technology implementation, pre– and post–quality improvement intervention).

This paper describes an empirical method that allows institutions and organizations to better understand the patterns by which consumers process cost and quality information.

Human expertise is limited by both cognitive workload and the boundaries of attention. With the spread and integration of healthcare informatics, cognitive decision support (CDS) technologies have been suggested as a means for improving the effectiveness and efficiency of healthcare. The current panel brings together leading human factors and medical experts in the fields of decision-making, design, and human-system interaction to provide their insight and perspective on the following question: What contributions can human factors science bring to bear on (1) the design, (2) integration, and (3) training necessary for effective CDS implementation?

Preventable patient harm due to errors in medication ordering, transcribing, dispensing and administration is a significant problem as discussed in the Institute of Medicine's 2007 report “Preventing Medication Errors”. Additionally, the report states that there are “enormous gaps in the knowledge base with regard to medication errors” and that the current methods available to solve this problem are inadequate (IOM, 2007, p2). Consequently, human factors research can contribute to the solution for this national problem by addressing the complexity in current medication systems and by designing user-centered solutions that support the real complex cognitive work of the clinicians. Panelists in this session, who have been funded by the federal government, private industry, and fellowships, will briefly share their human factors research on medication systems and then discuss how human factors researchers and practitioners can contribute to medication safety goals.

Health-related activities frequently occur outside of formal healthcare institutions, often in consumers' – “laypeople's” – homes. Within and near their homes, laypeople may use devices to self-monitor and self-manage wellness activities and chronic illnesses. They may keep health-related information records, using information technology applications to locate and retrieve information and communicate with formal and informal caregivers. Laypeople's engagement with the healthcare system and care outcomes rest on the quality of their interactions with, and use of, these devices and applications – jointly named consumer health informatics (CHI) interventions. Yet, engineering design and human factors evaluation methods are often omitted from the CHI intervention development process. This article presents a holistic human factors evaluation framework, and demonstrates how physical, cognitive and macroergonomic human factors perspectives can each improve the design and use of CHI interventions.

To reduce the probability of failures and to improve outcomes of safety-critical human-intensive processes, such as health care processes, it is important to be able to rigorously analyze such processes. The quality of that analysis often depends on having an accurate, detailed, and sufficiently complete understanding of the process being analyzed, where this understanding is typically represented as a formal process model that could then drive various rigorous analysis approaches. Developing this understanding and the corresponding formal process model may be difficult and, thus, a variety of process elicitation methods are often used. The work presented in this paper evaluates the effectiveness of five common elicitation methods in terms of their ability to elicit detailed process information necessary to support rigorous process analysis. These methods are employed to elicit typical steps and steps for responding to exceptional situations in a safety-critical health care process, the chemotherapy treatment plan review process. The results indicate strengths and weaknesses of each of the elicitation methods and suggest that it is preferable to apply multiple elicitation methods.

SummaryDespite widespread electronic health record (EHR) adoption, poor EHR system usability continues to be a significant barrier to effective system use for end users. One key to addressing usability problems is to employ user testing and user-centered design.To understand if redesigning an EHR-based navigation tool with clinician input improved user performance and satisfaction.A usability evaluation was conducted to compare two versions of a redesigned ambulatory navigator. Participants completed tasks for five patient cases using the navigators, while employing a think-aloud protocol. The tasks were based on Meaningful Use (MU) requirements.The version of navigator did not affect perceived workload, and time to complete tasks was longer in the redesigned navigator. A relatively small portion of navigator content was used to complete the MU-related tasks, though navigation patterns were highly variable across participants for both navigators. Preferences for EHR navigation structures appeared to be individualized.This study demonstrates the importance of EHR usability assessments to evaluate group and individual performance of different interfaces and preferences for each design.Citation: Hultman G, Marquard J, Arsoniadis E, Mink P, Rizvi R, Ramer T, Khairat S, Fickau K, Melton GB. Usability testing of two ambulatory EHR navigators.

In this clinical simulation study using an eye-tracking device, 40% of senior nursing students administered a contraindicated medication to a patient. Our findings suggest that the participants who did not identify the error did not know that amoxicillin is a type of penicillin. Eye-tracking devices may be valuable for determining whether nursing students are making rule- or knowledge-based errors, a distinction not easily captured via observations and interviews.

Summary Objective: Several studies have documented the preference for physicians to attend to the impression and plan section of a clinical document. However, it is not clear how much attention other sections of a document receive. The goal of this study was to identify how physicians distribute their visual attention while reading electronic notes. Methods: We used an eye-tracking device to assess the visual attention patterns of ten hospitalists as they read three electronic notes. The assessment included time spent reading specific sections of a note as well as rates of reading. This visual analysis was compared with the content of simulated verbal handoffs for each note and debriefing interviews. Results: Study participants spent the most time in the “Impression and Plan” section of electronic notes and read this section very slowly. Sections such as the “Medication Profile”, “Vital Signs” and “Laboratory Results” received less attention and were read very quickly even if they contained more content than the impression and plan. Only 9% of the content of physicians’ verbal handoff was found outside of the “Impression and Plan.” Conclusion: Physicians in this study directed very little attention to medication lists, vital signs or laboratory results compared with the impression and plan section of electronic notes. Optimizing the design of electronic notes may include rethinking the amount and format of imported patient data as this data appears to largely be ignored. Citation: Brown PJ, Marquard JL, Amster B, Romoser M, Friderici J, Goff S, Fisher D. What do physicians read (and ignore) in electronic progress notes? Appl Clin Inf 2014; 5: 430–444 http://dx.doi.org/10.4338/ACI-2014-01-RA-0003

Data from homecare electronic health records were used to explore the association of patient characteristics with re-hospitalizations of patients with heart failure (HF) during a 60-day period of telemonitoring following hospital discharge. Data from 403 Medicare patients with HF who had used telehealth from 2008 to 2010 were analysed. There were 112 all-cause (29%) and 73 cardiac-related (19%) re-hospitalizations within 60 days of being admitted to the homecare agency. In adjusted analyses, the patients’ prescribed number of medications and type of prescribed cardiac medications were significantly (P

Novice drivers are overrepresented in run-off-the-road crashes. Indeed, the previous literature demonstrates that novice drivers are less likely to anticipate hazards or maintain attention to the forward roadway and as a result fail to mitigate hazards by slowing. This research was an effort to compare the linked hazard anticipation and hazard mitigation behaviors of novice drivers with exemplary experienced drivers at curves, locations that are known to have a greater crash risk. Each driver navigated three drives in a driving simulator, one of which included a moderate curve left and one of which included a tightening curve right. Experienced drivers made more anticipatory glances and began slowing significantly earlier in the curves than did novice drivers. However, novice drivers who anticipated hazards were much more likely to also mitigate the hazard. The use of these results in a PC-based driver hazard mitigation training program will be discussed.

Article-at-a-Glance Background Chemotherapy ordering and administration, in which errors have potentially severe consequences, was quantitatively and qualitatively evaluated by employing process formalism (or formal process definition), a technique derived from software engineering, to elicit and rigorously describe the process, after which validation techniques were applied to confirm the accuracy of the described process. Methods The chemotherapy ordering and administration process, including exceptional situations and individuals' recognition of and responses to those situations, was elicited through informal, unstructured interviews with members of an interdisciplinary team. The process description (or process definition), written in a notation developed for software quality assessment purposes, guided process validation (which consisted of direct observations and semistructured interviews to confirm the elicited details for the treatment plan portion of the process). Results The overall process definition yielded 467 steps; 207 steps (44%) were dedicated to handling 59 exceptional situations. Validation yielded 82 unique process events (35 new expected but not yet described steps, 16 new exceptional situations, and 31 new steps in response to exceptional situations). Process participants actively altered the process as ambiguities and conflicts were discovered by the elicitation and validation components of the study. Chemotherapy error rates declined significantly during and after the project, which was conducted from October 2007 through August 2008. Discussion Each elicitation method and the subsequent validation discussions contributed uniquely to understanding the chemotherapy treatment plan review process, supporting rapid adoption of changes, improved communication regarding the process, and ensuing error reduction.

Introduction The CONDUIT-HID intervention integrates patients' electronic blood pressure measurements directly into the clinical EHR using Microsoft HealthVault as an intermediary data store. The goal of this paper is to describe generalizable categories of patient and technical challenges encountered in the development and implementation of this inexpensive, commercial off-the-shelf consumer health informatics intervention, examples of challenges within each category, and how the example challenges were resolved prior to conducting an RCT of the intervention. Methods The research team logged all challenges and mediation strategies during the technical development of the intervention, conducted home visits to observe patients using the intervention, and conducted telephone calls with patients to understand challenges they encountered. We then used these data to iteratively refine the intervention. Results The research team identified a variety of generalizable categories of challenges associated with patients uploading data from their homes, patients uploading data from clinics because they did not have or were not comfortable using home computers, and patients establishing the connection between HealthVault and the clinical EHR. Specific challenges within these categories arose because: (1) the research team had little control over the device and application design, (2) multiple vendors needed to coordinate their actions and design changes, (3) the intervention use cases were not anticipated by the device and application designers, (4) PHI accessed on clinic computers needed to be kept secure, (5) the research team wanted the data in the clinical EHR to be valid and reliable, (6) patients needed the ability to share only the data they wanted, and (7) the development of some EHR functionalities were new to the organization. While these challenges were varied and complex, the research team was able to successfully resolve each one prior to the start of the RCT. Conclusions By identifying these generalizable categories of challenges, we aim to help others proactively search for and remedy potential challenges associated with their interventions, rather than reactively responding to problems as they arise. We posit that this approach will significantly increase the likelihood that these types of interventions will be successful.

Aim: This paper reports a concept analysis of palliative care in the United States. Background: There has been a significant development of palliative care in the United States. The early years of 21st century have been characterized by a proliferation of diverse models of palliative care. Methods: A review of literature was conducted to explore the development of palliative care in the United States. Retrieved articles were published in English between years 2004 and 2011. Reference lists from relevant publications were reviewed. Rodgers’s evolutionary concept analysis strategy was used to guide this paper. The matrix method was used to analyze the identified articles. Results: The definition of palliative care has evolved in the United States in recent years. Six attributes were identified: (1) medical specialty, (2) holistic care, (3) patient- and family-centered care, (4) interdisciplinary team work, (5) effective communication, and (6) an integrated approach. The consequences of palliative care for patients, families, and medical institutions were from three aspects: (1) quality of life, (2) treatment and care, and (3) finances. The adapted palliative care model shows that palliative care should be integrated into illness management from the beginning of diagnosis and can be delivered concurrently with curative treatment through the whole trajectory of illness. Conclusions: Both the definition and application of palliative care have evolved over the last decade. The ultimate success of developing palliative care as a medical specialty will rest upon the integration of the changing concept of palliative care into everyday practice.

Patient identification (ID) errors occurring during the medication administration process can be fatal. The aim of this study is to determine whether differences in nurses' behaviors and visual scanning patterns during the medication administration process influence their capacities to identify patient ID errors. Nurse participants (n = 20) administered medications to 3 patients in a simulated clinical setting, with 1 patient having an embedded ID error. Error-identifying nurses tended to complete more process steps in a similar amount of time than non-error-identifying nurses and tended to scan information across artifacts (e.g., ID band, patient chart, medication label) rather than fixating on several pieces of information on a single artifact before fixating on another artifact. Non-error-indentifying nurses tended to increase their durations of off-topic conversations-a type of process interruption-over the course of the trials; the difference between groups was significant in the trial with the embedded ID error. Error-identifying nurses tended to have their most fixations in a row on the patient's chart, whereas non-error-identifying nurses did not tend to have a single artifact on which they consistently fixated. Finally, error-identifying nurses tended to have predictable eye fixation sequences across artifacts, whereas non-error-identifying nurses tended to have seemingly random eye fixation sequences. This finding has implications for nurse training and the design of tools and technologies that support nurses as they complete the medication administration process.

Objective The goal of this paper is to describe the successful application of a use case-based evaluation approach to guide the effective design, evaluation and redesign of inexpensive, commercial, off-the-shelf consumer health informatics (CHI) interventions. Design Researchers developed four CHI intervention use cases representing two distinct patient populations (patients with diabetes with high blood pressure, postbariatric surgery patients), two commercial off-the-shelf CHI applications (Microsoft HealthVault, Google Health), and related devices (blood pressure monitor, pedometer, weight scale). Three patient proxies tested each intervention for 10 days. Measurements The patient proxies recorded their challenges while completing use case tasks, rating the severity of each challenge based on how much it hindered their use of the intervention. Two independent evaluators categorized the challenges by human factors domain (physical, cognitive, macroergonomic). Results The use case-based approach resulted in the identification of 122 challenges, with 12% physical, 50% cognitive and 38% macroergonomic. Thirty-nine challenges (32%) were at least moderately severe. Nine of 22 use case tasks (41%) accounted for 72% of the challenges. Limitations The study used two patient proxies and addressed two specific patient populations and low-cost, off-the-shelf CHI interventions, which may not perfectly generalize to a larger number of proxies, actual patient populations, or other CHI interventions. Conclusion CHI designers can employ the use case-based evaluation approach to assess the fit of a CHI intervention with patients’ health work, in the context of their daily activities and environment, which would be difficult or impossible to evaluate by laboratory-based studies.

Quality of care is important in health care systems, and reducing medication errors is an effective approach to improve health care quality because medication errors are not rare and can cause adverse patient outcomes. Current researchers have adopted contextual, macro level methods to study the medication administration process, but the association between cognitive factors and the nurses' abilities to identify medication errors remains unclear. We used visual scanning patterns to study how nurses complete the medication administration process. In our study, we focused on a specific type of visual scanning pattern: nurses' two fixation scanpaths. We sought to find links between whether nurses identifies a patient identification error while administering a medication and their two fixation scanpaths. The data used in this study was collected in an experiment conducted at a Western Massachusetts hospital. Nurse participants wore an eye tracking device to record their eye movements while they performed a simulated medication administration process. We coded the eye tracking videos and analyzed the generated sequence data based on whether nurses identified a patient identification error during the process. We found that two fixation scanpaths are different between the two groups of nurses, those who identified the error and who did not. This finding may have implications for the design of medication administration protocol development.

Electronic reporting systems have the potential to support health care quality improvement initiatives across varied health care settings, specifically in low-technology settings such as long-term residential care facilities (LTRCFs). Yet, these organizations face financial barriers to implementing such systems and the LTRCF workforce is generally not as technology-ready as larger organizations’ workforces. Electronic reporting systems implemented in these settings must therefore be inexpensive and easy-to-use. This paper outlines a novel technique – process visualization – for systematically assessing the order in which users complete electronic forms, an inexpensively-developed patient falls reporting form in this case. These visualizations can help designers uncover usage patterns not evident via other usability methods. Based on this knowledge, designers can validate the design of the electronic forms, informing their subsequent redesign.

Motivation - Abstract surveys are currently the primary source of data guiding policy-makers as they frame laypeople's choices to electronically share their health information with care providers. Research approach - We presented laypeople (N=31) with two decision scenarios; one required them to choose whether to share their medication information with three types of physicians, the other required them to recommend sharing choices to four different patients. Findings/Design - Participants' sharing choices, their rationale for their choices, and their recommendations for other patients were contrary to what might be expected, given abstract survey responses. Research limitations/Implications - Our focus on sharing medication information with physicians and recruitment of only neurology patients limits the generalizability of the findings. Originality/Value -Walking decision-makers through realistic decision scenarios, and asking them to provide recommendations to other patients allowed us to assess laypeople's true decision criteria. This research therefore demonstrates the value of using realistic decision scenarios to inform policymaking.

Motivation - Patients face a new and complex set of choices in determining whether to electronically share their medication information with care providers. Research approach - We designed and tested a scorecard-type decision aid that structured and presented the benefits and concerns of sharing medication information to patients. Findings/Design - Patients' sharing choices and level of understanding did not vary based on their access to the decision aid, and they often did not use the aid. Research limitations/Implications - We tested the decision aid with only neurology patients, limiting the generalizability of the findings. Originality/Value - Our study describes an instance where decisionmakers without high levels of understanding felt confident about their ability to make choices and therefore did not reference a readily available decision aid. Take away message - Decision aids, to be more useful and widely used, should be designed based on decision-makers' behavioral manner of decision-making instead of normative decision-making paradigms.

Current health IT policy directions assume lay people want to make explicit choices about who can access elements of their health information. To test this assumption, we presented lay people (N=31) with a decision scenario that required them to choose whether to share their medication information with three different types of physicians. Participants generally chose to share all of their medication information, citing anticipated clinical care benefits as the main reason for their choices. They seemed, however, unaware of the possible consequences of their choices.

Motivation - The complex nature of health care processes requires new methods for describing, capturing and improving these processes. Research approach - We deployed a novel combination of methods - formal process modeling using a language called Little-JIL, simulations with embedded errors, observations, and eye tracking technology - to gauge how health care providers complete one complex process, patient identification. Findings/Design - These methods allowed us to thoroughly analyze how health care providers completed the patient identification process with and without embedded errors, and to record exactly what participants looked at during the simulations. Research limitations/Implications - We have used this set of methods to analyze only one type of health care process to-date. Originality/Value - We can use these approaches to inform health care provider training, process redesign, and the design of technologies to support health care providers as they verify patients' identities.

Legally and ethically, researchers are required to ensure laypeople understand the informed consent process. Characteristics of the potential participants, their situation, and the study have been shown to affect laypeople's understanding. We propose a seven-step design-for-understanding approach to the development of an understandable informed consent document. Results from application of the approach to a large bioinformatics field study, HeartCare II, are provided.

Exploring the context of use for informatics tools and applications can provide insight into requirements for their design. Historically, photographs have been used by social scientists as a way to study context in complex environments. Using data collected in the study "Advanced technologies for Health@Home" we share how photographs can be used to understand one such complex environment where informatics tools appear, the household. By capture, categorization, analysis and interpretation of photographs, we developed a richer understanding of information artifacts and the context of these artifacts used to support health information management in the household (HIMH). Photographs are an underused data source. Appropriately used, photographs can aid in the development of informatics resources that align with and extend current practices of health information management in the household (HIMH). Their use should be investigated further concerning other complex environments within nursing informatics.

89 Background: Chemotherapy order/administration consists of complex, interrelated processes where errors have potentially severe consequences. We report a study that quantitatively and qualitatively evaluated chemotherapy delivery employing a formal process definition language to elicit and describe rigorously the process, then applied mathematical validation techniques to confirm the description, analogously to how computer software development and other industries use accurate, precise process definitions to assure soundness through redundancy and correct event sequencing. Methods: The process, including exceptional situations and individuals’ recognition of and responses to these, was elicited through informal, unstructured interviews with members of an interdisciplinary team. The resulting process description (or process definition), written in a notation developed for software development process assessment, guided chemotherapy process validation consisting of rigorous process definition analysis, direct observations, and semi-structured interviews to confirm the elicited details for the treatment plan sub-process. Results: The overall process definition yielded 467 steps; 207 steps (44%) were dedicated to handling 59 exceptional situations. Validation yielded 82 unique process events (35 new expected but not yet described steps, 16 new exceptional situations, and 31 new steps in response to exceptional situations). Process participants actively altered the process as ambiguities and conflicts were discovered by the elicitation and validation components of the study. Chemotherapy error rates (evaluated by our safety reporting system) declined during and after the project (p

The development of Regional Health Information Organizations (RHIOs) has become an important priority for policymaking in the USA. These development efforts have focused primarily on data exchange. In this paper, we propose the use of a research approach, based on knowledge networks and collaboration, to develop an understanding of the processes associated with RHIO development. RHIOs need to be envisioned beyond the need to exchange electronic health information exchange and be seen as the catalyst for knowledge sharing of evidence-based medical practices. Sharing evidence-based medical and clinical practices allows for shared system improvement. Networks have been perceived as a foundation for forming inter-organisational collaborations. The term network implies a structure to relate social actors while collaboration is the process whereby social actors in the network take collective actions to achieve a common goal. RHIOs can serve as convener organisations that can act as a catalyst for bringing diverse stakeholders to work together toward a common purpose and a set of goals that benefit the community.