About the Project
Incident reporting has the potential to significantly reduce adverse events in healthcare but in the absence of the incidents being reported, system issues and risks cannot be identified or addressed. University Health Network (UHN) utilized an electronic reporting system that allowed hospital staff to report incidents and near misses. Healthcare Human Factors identified a major deficiency in this system in that staff could not proactively report hazards. Hazards are anything that increases the potential of an incident or near miss, and may include problems with the physical setting (lighting, noise, organization of materials), technology that is difficult to use, work patterns and procedures, forms, medication administration and many other issues.
Healthcare Human Factors, in conjunction with Risk Management and Software Engineering at UHN, redesigned the previously existing reporting system to include functionality for the reporting of hazards. This approach allows employees to proactively report issues in their workplace that could lead to an adverse event.
As of fall 2007, the hazard reporting form developed by the Healthcare Human Factors team has been in active use. Reported hazards are sent to the manager of the department and Risk Management, where the hazard is formally assessed and investigated. Where the opportunity arises, human factors experts are called upon to perform human factors analyses of the hazards and risks in order to provide proactive solutions and approaches to prevent incidents from reoccurring.