Evaluation and Outcomes of Multidisciplinary-Reported Incidents Regarding Patient Safety Management at Special Functioning Hospital in Japan — Oak Academic Publishing
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Evaluation and Outcomes of Multidisciplinary-Reported Incidents Regarding Patient Safety Management at Special Functioning Hospital in Japan
Division of Thoracic and Breast Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Division of Thoracic and Breast Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Division of Medical Safety Management, University of Miyazaki Hospital, Miyazaki, Japan
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Division of Medical Safety Management, University of Miyazaki Hospital, Miyazaki, Japan
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Division of Medical Safety Management, University of Miyazaki Hospital, Miyazaki, Japan
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Division of Clinical Ethics, University of Miyazaki Hospital, Miyazaki, Japan
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Division of Clinical Ethics, University of Miyazaki Hospital, Miyazaki, Japan
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Division of Thoracic and Breast Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Division of Cardiovascular Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
1 Division of Thoracic and Breast Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
2 Division of Thoracic and Breast Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
3 Division of Medical Safety Management, University of Miyazaki Hospital, Miyazaki, Japan
4 Division of Medical Safety Management, University of Miyazaki Hospital, Miyazaki, Japan
5 Division of Medical Safety Management, University of Miyazaki Hospital, Miyazaki, Japan
6 Division of Clinical Ethics, University of Miyazaki Hospital, Miyazaki, Japan
7 Division of Clinical Ethics, University of Miyazaki Hospital, Miyazaki, Japan
8 Division of Thoracic and Breast Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
9 Division of Cardiovascular Surgery, Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
Background: It is an important study to investigate incident reports submitted by multidisciplinaries in the Special Functioning Hospitals of Japan. We clarify the characteristics of the incidents and evaluate the outcomes obtained from a polygonal analysis. Material and Methods: We collected 1638 incident reports submitted by multidisciplinaries for one year from April, 2016 to March, 2017. The incidents were retrospectively analyzed by profile, levels, distribution, and ratios. Results: The majority of incidents (94.7%, 1551/1638) were distributed between the levels 0 to 3a, on the other hand, the incidents of a level higher than 3b occupied 5.3%. The reports from nurses were 75.3% (1234/1638) and those from doctors were 12.8% (209/1638). The level 3b totalled 30.6% (64/209) of the doctor-reported incidents. In contrast, the level 2 totalled 33.8% (417/1234) of the nurse-reported incidents. The levels of th e doctor-incidents were comparatively higher than those of the nurse-incidents. The profiles of the incidents were categorized as drug administration (n = 439, 26.8%), nursing care (n = 399, 24.4%), drain and tube (n = 258, 15.8%), medical treatment and care (n = 199, 12.1%), medical examination (n = 141, 8.6%), medical equipment (n = 99, 6.0%), giving instructions (n = 66, 4.0%) and blood transfusion (n = 12, 0.7%). Conclusions: It is important for multidisciplinaries to report incidents because they can learn novel experiences from the incidents for preventing a recurrence. By proper utilizing of the incident-reporting system, it could be an effective tool that helps the medical staff build a strong patient safety culture, and a safer workday would improve their quality of healthcare.
Vincent, C.A. (2004) Analysis of Clinical Incidents: A Window on the System Not a Search for Root Causes. BMJ Quality & Safety, 13, 242-243. https://doi.org/10.1136/qshc.2004.010454
Leistikow, I., Mulder, S., Vesseur, J. and Robben, P. (2017) Learning from Incidents in Healthcare: The Journey, Not the Arrival, Matters. BMJ Quality & Safety, 26, 252-256. https://doi.org/10.1136/bmjqs-2015-004853
Kohn, K.T., Corrigan, J.M. and Donaldson, M.S. (2000) To Err Is Human: Building a Safer Health System. National Academy Press, Washington, DC.
Department of Health. An Organization with a Memory, 2000. http://www.dh.gov.uk/assetRoot/04/08/89/48/04088948.pdf
World Health Organization (2005) World Alliance for Patient Safety: WHO Draft Guidelines for Adverse Event Reporting and Learning Systems: From Information to Action. World Health Organization, Geneva. http://www.sho.int/iris/handle/10665/69797
Giles, S., Fletcher, M., Baker, M. and Thomson, R. (2005) Incident Reporting and Analysis. In: Walshe, K. and Boaden, R., Eds., Patient Safety: Research into Practice, Open University Press, Buckingham.
Evans, S.M., Berry, J.G., Smith, B.J., Esterman, A., Selim, P., O’Shaughnessy, J. and DeWit, M. (2006) Attitudes and Barriers to Incident Reporting: A Collaborative Hospital Study. Quality and Safety in Health Care, 15, 39-43. https://doi.org/10.1136/qshc.2004.012559
Kingston, M.J., Evans, S.M., Smith, B.J. and Berry, J.G. (2004) Attitudes of Doctors and Nurses towards Incident Reporting: A Qualitative Analysis. The Medical Journal of Australia, 181, 36-39.
Schectman, J.M. and Plews-Ogan, M.L. (2006) Physician Perception of Hospital Safety and Barriers to Incident Reporting. Joint Commission Journal on Quality and Patient Safety, 32, 337-343. https://doi.org/10.1016/S1553-7250(06)32043-0
Waring, J.J. and Waring, J.J. (2005) Beyond Blame: Cultural Barriers to Medical Incident Reporting. Social Science & Medicine, 60, 1927-1935. https://doi.org/10.1016/j.socscimed.2004.08.055
Johnson, C.W. (2003) How Will We Get the Data and What Will We Do with It Then? Issues in the Reporting of Adverse Healthcare Events. Quality and Safety in Health Care, 12, ii64-ii67. https://doi.org/10.1136/qhc.12.suppl_2.ii64
Zeeshan, M.F., Dembe, A.E., Seiber, E.E. and Lu, B. (2014) Incidence of Adverse Events in an Integrated US Healthcare System: A Retrospective Observational Study of 82,784 Surgical Hospitalizations. Patient Safety in Surgery, 8, 23. https://doi.org/10.1186/1754-9493-8-23
Bratzler, D.W. and Hunt, D.R. (2006) The Surgical Infection Prevention and Surgical Care Improvement Projects: National Initiatives to Improve Outcomes for Patients Having Surgery. Clinical Infectious Diseases, 43, 322-330. https://doi.org/10.1086/505220
Rowell, K.S., Turrentine, F.E., Hutter, M.M., Khuri, S.F. and Henderson, W.G. (2007) Use of National Surgical Quality Improvement Program Data as a Catalyst for Quality Improvement. Journal of the American College of Surgeons, 204, 1293-1300. https://doi.org/10.1016/j.jamcollsurg.2007.03.024
Hall, B.L., Hamilton, B.H., Richards, K., Bilimoria, K.Y., Cohen, M.E. and Ko, C.Y. (2009) Does Surgical Quality Improve in the American College of Surgeons National Surgical Quality Improvement Program: An Evaluation of All Participating Hospitals. Annals of Surgery, 250, 363-376. https://doi.org/10.1097/SLA.0b013e3181b4148f
Wu, A.W., Folkman, S., McPhee, S.J. and Lo, B. (2003) Do House Officers Learn from Their Mistakes? Quality and Safety in Health Care, 12, 221-226. https://doi.org/10.1136/qhc.12.3.221
Farley, D.O., Haviland, A., Haas, A., Pham, C., Munier, W.B. and Battles, J.B. (2012) How Event Reporting by US Hospitals Has Changed from 2005 to 2009. BMJ Quality & Safety, 21, 70-77. https://doi.org/10.1136/bmjqs-2011-000114
Makary, M.A. and Daniel, M. (2016) Medical Error—The Third Leading Cause of Death in the US. BMJ, 353, i2139. https://doi.org/10.1136/bmj.i2139
Milch, C.E., Salem, D.N., Pauker, S.G., Lundquist, T.G., Kumar, S. and Chen, J. (2996) Voluntary Electronic Reporting of Medical Errors and Adverse Events. An Analysis of 92,547 Reports from 26 Acute Care Hospitals. Journal of General Internal Medicine, 21, 165-170.
Kivlahan, C., Sangster, W., Nelson, K., Buddenbaum, J. and Lobenstein, K. (2002) Developing a Comprehensive Electronic Adverse Event Reporting System in an Academic Health Center. The Joint Commission Journal on Quality Improvement, 28, 583-594. https://doi.org/10.1016/S1070-3241(02)28062-1
Paradis, A.R., Stewart, V.T., Bayley, K.B., Brown, A. and Bennett, A.J. (2009) Excess Cost and Length of Stay Associated with Voluntary Patient Safety Event Reports in Hospitals. American Journal of Medical Quality, 24, 53-60. https://doi.org/10.1177/1062860608327610
Sutcliffe, K.M. (2011) High Reliability Organizations (HROs). Best Practice & Research: Clinical Anaesthesiology, 25, 133-144. https://doi.org/10.1016/j.bpa.2011.03.001
Barach, P. and Small, S.D. (2000) Reporting and Preventing Medical Mishaps: Lessons from Non-Medical near Miss Reporting Systems. BMJ, 320, 759-763. https://doi.org/10.1136/bmj.320.7237.759
Van Spall, H., Kassam, A. and Tollefson, T.T. (2015) Near-Misses Are an Opportunity to Improve Patient Safety: Adapting Strategies of High Reliability Organizations to Healthcare. Current Opinion in Otolaryngology & Head and Neck Surgery, 23, 292-296. https://doi.org/10.1097/MOO.0000000000000177
Farley, D.O., Haviland, A., Champagne, S., Jain, A.K., Battles, J.B., Munier, W.B. and Loeb, J.M. (2008) Adverse-Event-Reporting Practices by US Hospitals: Results of a National Survey. Quality and Safety in Health Care, 17, 416-423. https://doi.org/10.1136/qshc.2007.024638
Jansma, J.D., Wagner, C., Ten Kate, R.W. and Bijnen, A.B. (2011) Effects on Incident Reporting after Educating Residents in Patient Safety: A Controlled Study. BMC Health Services Research, 11, 335. https://doi.org/10.1186/1472-6963-11-335
Varkey, P., Karlapudi, S., Rose, S. and Swensen, S. (2009) A Patient Safety Curriculum for Graduate Medical Education: Results from a Needs Assessment of Educators and Patient Safety Experts. American Journal of Medical Quality, 24, 214-221. https://doi.org/10.1177/1062860609332905
Reason, J. (1995) Understanding Adverse Events: Human Factors. Quality in Health Care, 4, 80-89. https://doi.org/10.1136/qshc.4.2.80
Walton, M.M. and Elliott, S.L. (2006) Improving Safety and Quality: How Can Education Help? The Medical Journal of Australia, 184, S60-S64.
Vincent, C., Taylor-Adams, S., Chapman, E.J., Hewett, D., Prior, S., Strange, P. and Tizzard, A. (2000) How to Investigate and Analyse Clinical Incidents: Clinical Risk Unit and Association of Litigation and Risk Management Protocol. BMJ, 320, 777-781. https://doi.org/10.1136/bmj.320.7237.777
Naveh, E., Katz-Navon, T. and Stern, Z. (2006) Readiness to Report Medical Treatment Errors: The Effects of Safety Procedures, Safety Information, and Priority of Safety. Medical Care, 44, 117-123. https://doi.org/10.1097/01.mlr.0000197035.12311.88
Hutchinson, A., Young, T.A., Cooper, K.L., McIntosh, A., Karnon, J.D., Scobie, S. and Thomson, R.G. (2009) Trends in Healthcare Incident Reporting and Relationship to Safety and Quality Data in Acute Hospitals: Results from the National Reporting and Learning System. Quality and Safety in Health Care, 18, 5-10. https://doi.org/10.1136/qshc.2007.022400
Mandavia, R., Yassin, G., Dhar, V. and Jacob, T. (2013) Completing the Audit Cycle: The Impact of an Electronic Reporting System on the Feedback Loop in Surgical Specialties. Journal for Healthcare Quality, 35, 16-23. https://doi.org/10.1111/jhq.12040
Uribe, C.L., Schweikhart, S.B., Pathak, D.S., Dow, M. and Marsh, G.B. (2002) Perceived Barriers to Medical-Error Reporting: An Exploratory Investigation. Journal of Healthcare Management, 47, 263-279. https://doi.org/10.1097/00115514-200207000-00009
Evans, S.M., Smith, B.J., Esterman, A., Runciman, W., Maddern, G., Stead, K., Selim, P., O’Shaughnessy, J., Muecke, S. and Jones, S. (2007) Evaluation of an Intervention Aimed at Improving Voluntary Incident Reporting in Hospitals. Quality and Safety in Health Care, 16, 169-175. https://doi.org/10.1136/qshc.2006.019349
Sari, A.B., Sheldon, T.A., Cracknell, A. and Turnbull, A. (2007) Sensitivity of Routine System for Reporting Patient Safety Incidents in an NHS Hospital: Retrospective Patient Case Note Review. BMJ, 334, 79. https://doi.org/10.1136/bmj.39031.507153.AE
Christiaans-Dingelhoff, I., Smits, M., Zwaan, L., Lubberding, S., van der, W.G. and Wagner, C. (2011) To What Extent Are Adverse Events Found in Patient Records Reported by Patients and Healthcare Professionals via Complaints, Claims and Incident Reports? BMC Health Services Research, 11, 49. https://doi.org/10.1186/1472-6963-11-49
Hwang, J.I., Lee, S.I. and Park, H.A. (2012) Barriers to the Operation of Patient Safety Incident Reporting Systems in Korean General Hospitals. Healthcare Informatics Research, 18, 279-286. https://doi.org/10.4258/hir.2012.18.4.279
Welsh, C.H., Pedot, R. and Anderson, R.J. (1996) Use of Morning Report to Enhance Adverse Event Detection. Journal of General Internal Medicine, 11, 454-460. https://doi.org/10.1007/BF02599039
Figueiras, A., Herdeiro, M.T., Polónia, J. and Gestal-Otero, J.J. (2006) An Educational Intervention to Improve Physician Reporting of Adverse Drug Reactions: A Cluster-Randomized Controlled Trial. JAMA, 296, 1086-1093. https://doi.org/10.1001/jama.296.9.1086
Jansma, J.D., Zwart, D.L., Leistikow, I.P., Kalkman, C.J., Wagner, C. and Bijnen, A.B. (2010) Do Specialty Registrars Change Their Attitudes, Intentions and Behaviour towards Reporting Incidents Following a Patient Safety Course? BMC Health Services Research, 10, 100. https://doi.org/10.1186/1472-6963-10-100
Jansma, J.D., Wagner, C., ten Kate, R.W. and Bijnen, A.B. (2011) Effects on Incident Reporting after Educating Residents in Patient Safety: A Controlled Study. BMC Health Services Research, 11, 335. https://doi.org/10.1186/1472-6963-11-335
Mathers, L.J. and Weiss, H.B. (1998) Incidence and Characteristics of Fall-Related Emergency Department Visits. Academic Emergency Medicine, 5, 1064-1070. https://doi.org/10.1111/j.1553-2712.1998.tb02663.x
Grisso, J.A., Schwarz, D.F., Wishner, A.R., Weene, B., Holmes, J.H. and Sutton, R.L. (1990) Injuries in an Elderly Inner-City Population. Journal of the American Geriatrics Society, 38, 1326-1331. https://doi.org/10.1111/j.1532-5415.1990.tb03456.x
Van Weel, C., Vermeulen, H. and van den Bosch, W. (1995) Falls, a Community Care Perspective. The Lancet, 345, 1549-1551. https://doi.org/10.1016/S0140-6736(95)91091-3
Hill, A.M., McPhail, S.M., Waldron, N., Etherton-Beer, C., Ingram, K., Flicker, L., Bulsara, M. and Haines, T.P. (2015) Fall Rates in Hospital Rehabilitation Units after Individualised Patient and Staff Education Programmes: A Pragmatic, Stepped-Wedge, Cluster-Randomised Controlled Trial. The Lancet, 385, 2592-2599. https://doi.org/10.1016/S0140-6736(14)61945-0
Rizzo, J.A., Friedkin, R., Williams, C.S., Nabors, J., Acampora, D. and Tinetti, M.E. (1998) Health Care Utilization and Costs in a Medicare Population by Fall Status. Medical Care, 36, 1174-1788. https://doi.org/10.1097/00005650-199808000-00006
Nordell, E., Jarnlo, G.B., Jetsén, C., Nordstrom, L. and Thorngren, K.G. (2000) Accidental Falls and Related Fractures in 65-74 Year Olds: A Retrospective Study of 332 Patients. Acta Orthopaedica Scandinavica, 71, 175-179. https://doi.org/10.1080/000164700317413157
Imagama, S., Ito, Z., Wakao, N., Seki, T., Hirano, K., Muramoto, A., Sakai, Y., Matsuyama, Y., Hamajima, N., Ishiguro, N. and Hasegawa, Y. (2013) Influence of Spinal Sagittal Alignment, Body Balance, Muscle Strength, and Physical Ability on Falling of Middle-Aged and Elderly Males. European Spine Journal, 22, 1346-1353. https://doi.org/10.1007/s00586-013-2721-9
Kobayashi, K., Imagama, S., Inagaki, Y., Suzuki, Y., Ando, K., Nishida, Y., Nagao, Y. and Ishiguro, N. (2017) Incidence and Characteristics of Accidental Falls in Hospitalizations. Nagoya Journal of Medical Science, 79, 291-298.
Nagao, Y., Kamemori, Y. and Kuwahara, N. (2013) Incident Report No Hatasu Yakuwari to Kadaikaiketsu Notameno Shiten. Journal of Patient Safety Promotion, 33, 10-18. (In Japanese)
Dan, H., Uema, A. and Shinkai, H. (2010) Incident Report Saiko, Iryoanzen Kotohajima, Igakushoin. 21-34. (In Japanese)
Reason, J. (2000) Human Error: Models and Management. BMJ, 320, 768-770. https://doi.org/10.1136/bmj.320.7237.768
NHS England (2015) Patients Safety Domain; Revised Never Events Policy and Framework. London.
Jensen, L.S., Merry, A.F., Webster, C.S., Weller, J. and Larsson, L. (2004) Evidence-Based Strategies for Preventing Drug Administration Errors during Anaesthesia. Anaesthesia, 59, 493-504. https://doi.org/10.1111/j.1365-2044.2004.03670.x
Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Chu, H., Cosgrove, S., Sexton, B., Hyzy, R., Welsh, R., Roth, G., Bander, J., Kepros, J. and Goeschel, C. (2006) An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. The New England Journal of Medicine, 355, 2725-2732. https://doi.org/10.1056/NEJMoa061115
Gaba, D.M. (2000) Anaesthesiology as a Model for Patient Safety in Health Care. BMJ, 320, 785-788. https://doi.org/10.1136/bmj.320.7237.785
Catchpole, K., Mishra, A., Handa, A. and McCulloch, P. (2008) Teamwork and Error in the Operating Room: Analysis of Skills and Roles. Annals of Surgery, 247, 699-706. https://doi.org/10.1097/SLA.0b013e3181642ec8