A REPORTING SYSTEM OF DIFFICULTIES AND HAZARDS IN HOSPITAL WARDS AS A GUIDE FOR IMPROVING HUMAN FACTORS AND SAFETY

摘要

Cotemporary efforts for improving healthcare safety are almost exclusively dependent on the study of adverse events as their primary information source. Investigations of adverse events have had an important role and contribution to the recognition of the magnitude of the healthcare problem, but are of a limited scientific value. Error investigations are the wisdom of hindsight, based on partial and biased sample, lacking base rate reference and distorted by reporter’s memory and interests. This paper describes an alternative approach based on self reports of medical staff, on daily reoccurring hazards and performance difficulties, representing human factors and safety aspects. Reports are evaluated by a human factors team, and corrective steps are proposed, and backed by management. We describe the logic and elements of the new approach, and bring results from four wards belonging to two hospitals. These results are compared with data obtained in 5 years, using conventional incident reporting systems.