Intervention
A process map, then Strengths, Weaknesses, Opportunities, and Threats
(SWOT) analysis, was completed to identify bottlenecks in reporting
systems and pragmatic methods available to strengthen current systems.
The outcomes of these analyses are presented in Figure 1. Based on the
gaps identified in the pre-intervention phase, the following
interventions were agreed upon by the project team:
- refinement of existing process and systems for near-miss reporting.
- development of guidelines to facilitate near-miss reporting; and
- the design of a user-friendly near-miss reporting format.