Medical Event Data Collection and Analysis Service (MEDCAS)

The MEDCAS project seeks to create an organization of technically-qualified medical and human factors professionals trained in forensics to assist healthcare organizations to learn from and lessen the likelihood of adverse events, in the manner of a "National Patient Safety Board."
     Phase One (2005) demonstrated the need and organization for adverse events investigation. 
     Phase Two (2006-7) demonstrated through a 15-month pilot program how an external professional technical service can help acute care hospital Pediatric Intensive Care Units (PICUs) to learn from and reduce adverse events.  Funding for the MEDCAS Phase Two was provided by VHA Health Foundation, and the Center for Device and Radiological Health, US Food and Drug Administration.
    Phase Three will demonstrate the role of external adverse event investigation as a larger scale organization.

Reports

Cook, R. and Nemeth, C. (2007, May). MEDCAS Phase Two Final Report.

Cook, R. and Nemeth, C. (2007, April). The Milrinone Event: Report of an External Investigation.

Cook, R. and Nemeth, C. (2007, February). OSI Table: Report of an External Investigation.

Professional papers

Nemeth, C., Dierks, M., Patterson, E, Donchin, Y.,  Crowley, J. McNee, S., Powell, T., and Cook, R.I. Learning from Investigation. (2006, October) Proceedings of the Human Factors and Ergonomics Society Annual Meeting. San Francisco.

Nemeth, C., Cook, R., Crowley, J., Ragan, M., Battles, J., Smithson, K., and Bruley, M. (2005, September) Above Board: Issues in Medical Accident Investigation and Analysis. Proceedings of the Human Factors and Ergonomics Society National Conference. Orlando.

Nemeth, C., Cook, R.I., Patterson, E., Donchin, Y., Rogers, M., and Ebright, P. (2004, September). Afterwords: The Quality of Medical Accident Investigation and Analyses. Proceedings of the Human Factors and Ergonomics Society National Conference. New Orleans.