This paper presents Determining Information flow Breakdown (DIB), a method for analyzing adverse events in clinical environments from the perspective of breakdowns in information flow. The larger context for DIB is that it is the first stage in a process that promotes organizational learning in response to adverse events through the design of novel IT solutions. DIB is based on the theoretical view of distributed cognition and adopts a system-wide view of failures. DIB is both a reactive and a proactive method in that it aims to locate the causes of either actual or potential adverse events by investigating all elements of the system related to a chosen aspect of patient care. It was developed and evolved using a case study approach whereby data on actual and potential adverse events in clinical environments was collected, modeled and analyzed using successive versions of the method. We provide an explanation and overview of the DIB method, and discuss our experiences of applying it in practice via a detailed example. © 2006 Elsevier Ireland Ltd. All rights reserved.
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