Chapter M: Human Factors of Reporting Systems

A number of mechanisms that can be used to elicit epidemiological information about advere events in healthcare. Morbidity and mortality committees provide a primary means of detecting potential problems in the quality of patient care (Wald and Shojania, 2001). Litigation and malpractice statistics focus attention on incidents and accidents. The publication of clinical studies also helps to ensure that medical practice remains at a high level within particular organisations. However, these epidemiological techniques often provide insights many months and years after the original incidents have occurred. They also are often limited in terms of the insights they provide into mitigation and error reduction strategies. Other techniques such as chart reviews and the use of automated detection systems provide limited information about the causes of adverse events and can provide results that are both partial and biased. This chapter focusses on the role that mandatory and voluntary reporting systems can play in improving patient safety. M.1 Introduction to the Human Factors of Adverse Events Human factors play a dual role in healthcare. On the one hand, we rely upon individual and team decision making to guide most aspects of diagnosis and treatment. We rely o