title: Human factors-focused reporting system for improving care quality and safety in hospital wards.
abstract: OBJECTIVE
  The aim was to develop a reporting system for collecting human factors problem reports to establish a database to guide activities for improving health care quality and patient safety.
  
  
  BACKGROUND
  The current error and incident report systems do not provide sufficient and adequate coverage of the factors contributing to impaired safety and care quality. They fail to examine the range of difficulties that clinical staff encounters in the conduct of daily work.
  
  
  METHODS
  A voluntary problem-reporting system was developed to be used by hospital wards' clinicians and was tested in four wards of two hospitals in Israel. The system is based on human factors--formatted problem reports submitted by physicians and nurses on difficulties and hazards they confront in their daily work. Reports are grouped and evaluated by a team of human factor professionals.
  
  
  RESULTS
  A total of 359 reports were collected in the wards during 12 weeks, as compared with a total of 200 incidents reports that were collected during a period of 5 years with the existing obligatory incident reporting system. In-depth observational studies conducted on the wards confirmed the ability of the new system to highlight major human factors problems, differentially identifying specific problems in each of the wards studied. Problems reported were directly related to general factors affecting care quality and patient safety.
  
  
  CONCLUSIONS
  Validation studies confirmed the reliability of the reporting system in pinpointing major problems per investigated unit according to its specific characteristics.
  
  
  CONCLUSIONS
  This type of reporting system could fill an important information gap with the potential to be a cost-effective initial database source to guide human factors efforts to improve care quality, reduce errors, and increase patient safety.
authors.affiliation: Technion-Israel Institute of Technology, Haifa 32000, Israel. idomorag@shenkar.ac.il
authors.forename: Ido
authors.initials: I
authors.lastname: Morag
authors.forename: Daniel
authors.initials: D
authors.lastname: Gopher
authors.forename: Avishag
authors.initials: A
authors.lastname: Spillinger
authors.forename: Yael
authors.initials: Y
authors.lastname: Auerbach-Shpak
authors.forename: Neri
authors.initials: N
authors.lastname: Laufer
authors.forename: Yuval
authors.initials: Y
authors.lastname: Lavy
authors.forename: Ariel
authors.initials: A
authors.lastname: Milwidsky
authors.forename: Rivka-Rita
authors.initials: RR
authors.lastname: Feigin
authors.forename: Shimon
authors.initials: S
authors.lastname: Pollack
authors.forename: Itay
authors.initials: I
authors.lastname: Maza
authors.forename: Zaher S
authors.initials: ZS
authors.lastname: Azzam
authors.forename: Hanna
authors.initials: H
authors.lastname: Admi
authors.forename: Michael
authors.initials: M
authors.lastname: Soudry
mesh_terms: D003142:Communication; D003625:Data Collection / Q000592:standards; D016208:Databases, Factual; D006804:Ergonomics; D006801:Humans; D007400:Interprofessional Relations; D016272:Occupational Health; D010348:Patient Care Team; D011787:Quality of Health Care; D012308:Risk Management / Q000458:organization & administration* / Q000592:standards