Analysis of Medication Incidents Nationwide With a Focus on Individual Elements of the Work Process  

Oleh:

Sano, Masataka ; Munechika, Masahiko ; Kajihara, Chisato ; Hamada, Chikuma

Jenis: Article from Proceeding
Dalam koleksi: 12th ANQ Congress in Singapore, 5-8 Agustus 2014, page 1-6.
Topik: Medication incidents; Patient Safety; Tasks; Error-proofing; JCQHC
Fulltext: HC1-1.6-P0263.pdf (177.23KB)

Isi artikel

Reducing the incidence of adverse events and improving patient safety should be among the highest priorities of a healthcare institution. Healthcare institutions implement incident reporting systems so that they can learn from previous mistakes. Although Japan has a nationwide system for reporting near-miss events, appropriate countermeasures have not yet been established for many of these types of incidents; thus, it is recommended that each hospital develop its own countermeasures to prevent recurrences of the incidents. This study analysed medication incidents that occurred around the nation, using the list of 25 individual tasks (elements of the medication administration process) that has been developed. This study drew data from the near-miss reports that have been published by the JCQHC (Japan Council for Quality Health Care). We analysed 195 cases that occurred from 2008 to 2011. The analyses were conducted in the following steps: (1) For each report, a list of the individual tasks mentioned was created; (2) the report was analysed to determine which specific task(s) in the process were involved with the error; (3) the earliest of the tasks in which the error was involved was determined; and (4) A suggested countermeasure to apply to the selected task, in order to prevent recurrence of the error, was devised. The results showed that the largest number of incidents (44) began at Task No.4, which is the prescribing of medication, and involves inputting the description of the required medication into the information media to transmit the order. One hundred and seven of the incidents began in the first three tasks, which are upstream of the actual prescribing of the medication. We also discuss the kinds of information that should be collected to help in developing appropriate error-proofing countermeasures that can be delivered to healthcare institutions around the world

Opini Anda

Klik untuk menuliskan opini Anda tentang koleksi ini!

Kembali