טכניון מכון טכנולוגי לישראל
הטכניון מכון טכנולוגי לישראל - בית הספר ללימודי מוסמכים  
Ph.D Thesis
Ph.D StudentIdo Morag
SubjectA Novel Reporting System for the Improvement of Human
Factors and Safety in Hospital Wards
DepartmentDepartment of Industrial Engineering and Management
Supervisors Full Professor Erev Ido
Professor Emeritus Gopher Daniel
Full Thesis text - in Hebrew Full thesis text - Hebrew Version


Abstract

Due to the highly charged work environments and extremely complex systems that prevail in hospital wards, medical teams are liable to commit mistakes affecting patient safety. The question arises as to how this can be prevented and the possibility that the medical environment can be evaluated - and safety and efficiency enhanced.


Current efforts to improve patient safety in hospitals focus upon the investigation and study of accidents, incidents, errors and adverse events. The prime source of information about these events is incident reports that medical personnel file. This approach fails to examine the various difficulties and obstacles with which the medical team has to deal with daily and which are the source of the adverse events in the first place.

The understanding that human factors engineering has the tools for reducing human errors and improving patient safety offers the possibility of using this framework as the means for developing a complementary approach to the current reporting system. The development of the complementary approach consisted of three stages: 

1. Development of reporting forms.

2. Implementation of reporting system, with the reports collected from four wards at Hadassah Medical Center, Jerusalem and Rambam Health Care Campus, Haifa.  

3. Validation studies of focal reported problems in the four wards. .

 

Results

Number of reports collected - In Hadassah there were 241 reports in 12 weeks using the proactive reporting system. In five years, the incident reporting system had only generated 51 reports. In Rambam there were 118 problem reports in 12 weeks vs. 149 incidents reports in five years.

Reporting source - With the proactive reporting system, the physicians, contrary to prior behavior, contributed a significant number of reports -- 21% to 42% of the total number of reports that were filed in the four wards.

Problems raised - While fall events and medication errors were the most frequent categories in incident reports, they are rare in the proactive reporting system. In the latter system, primary concerns were: work procedure and patterns; instrumentation; and physical setting. 


Summary

The proactive system is highly effective in locating problems that significantly affect the medical staff and the safety of the patients:                                                                                                                       

1.      Produces datasets that more accurately represent the totality of activities in a particular unit. 

2.      Generates a detailed understanding of wards problems that both nurses and physicians encounter.

3.      Provides healthcare decision-makers with larger - and therefore more accurate -- sample of problems and topics.