Better Accident Investigations in Healthcare Settings: Understanding & Preventing Human Error - April 20, 2009

Gander, Newfoundland

Adverse events related to patient violence, infection control issues, manual materials and patient handling, needle sticks and falls involving seniors are everyday concerns in the healthcare setting.

Often investigations find human error as a main contributor to these accidents and incidents. Rather than a conclusion, this should be the starting point of an in depth investigation that will not only determine the various factors that lead to the error, but allow for better design of the equipment, environment, processes, systems and training related to the job tasks involved.

The workshop will cover the role of human factors in such events, why it is important to investigate for these factors and how to systematically investigate for human factors-related cause factors.

Using case studies, participants will develop and rehearse practical skills necessary to conduct investigations such as interviewing, fact gathering, constructing sequence of events diagrams, identifying and analyzing unsafe behaviours, synthesizing contributing factors and providing safety recommendations.


The workshop will be of interest to all healthcare workers interested in developing skill in effectively investigating the causes of adverse events in their environment. This includes OHS Committee members, Ergonomists, Accident/Incident Investigators, OHS and Risk Managers, falls prevention committee members and Injury Prevention Coordinators in clinics, community health, consulting firms, long-term care facilities and other related settings.