Research into improving the safety of healthcare systems has recently focused on learning how incidents of harm to patients happen and how to prevent them. Although it is acknowledged that low participation in incident-reporting systems contributes to the problem of poor error prevention, little research has focused on improving participation. This research is focused on how both participation in and use of incident-reporting systems can be improved by examining the usability of the reporting tools. A large private hospital in the northeastern United States and the incident reporting app used there were examined as a case study. A mixed-methods approach using Critical Decision Method interviews, heuristic usability tests, and surveys was used. Seemingly minor usability issues like inconvenient and hard to read menus were found to inhibit both the quantity and quality of incident reports. Additionally, despite the organization having a generally strong safety culture, there were organizational obstacles to the reporting of incidents and the adoption of useful interventions in response to incidents beyond what is normally encompassed by the term “safety culture”. Specific recommendations for hospital incident reporting process improvement are included.

Library of Congress Subject Headings

Medical errors--Prevention; Hospital care--Safety measures; Industrial safety--Psychological aspects; User-centered system design

Publication Date


Document Type


Student Type


Degree Name

Experimental Psychology (MS)

Department, Program, or Center

Psychology (CLA)


Esa Rantanen

Advisor/Committee Member

Heidi Mix

Advisor/Committee Member

Karlee Haschmann


Physical copy available from RIT's Wallace Library at RA972 .W43 2016


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