Background: It is an important study to investigate incident reports submitted by multidisciplinariesinthe Special Functioning Hospitals ofJapan. We clarify thecharacteristics of the incidents and evaluate the outcomes obtained from a polygonal analysis.Material and Methods:We collected 1638 incident reports submitted by multidisciplinariesfor one year from April, 2016 to March, 2017.The incidents were retrospectively analyzed byprofile, 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 levelhigher than 3b occupied 5.3%.The reports from nurses were 75.3% (1234/1638)and those from doctorswere 12.8% (209/1638). The level 3b totalled30.6% (64/209) of the doctor-reported incidents. In contrast, the level 2
References
[1]
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
[2]
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
[3]
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.
[4]
Department of Health. An Organization with a Memory, 2000.
http://www.dh.gov.uk/assetRoot/04/08/89/48/04088948.pdf
[5]
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
[6]
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.
[7]
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
[8]
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.
[9]
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
[10]
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
[11]
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
[12]
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
[13]
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
[14]
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
[15]
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
[16]
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
[17]
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
[18]
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
[19]
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.
[20]
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
[21]
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
[22]
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
[23]
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
[24]
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
[25]
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
[26]
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
[27]
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
[28]
Reason, J. (1995) Understanding Adverse Events: Human Factors. Quality in Health Care, 4, 80-89. https://doi.org/10.1136/qshc.4.2.80
[29]
Walton, M.M. and Elliott, S.L. (2006) Improving Safety and Quality: How Can Education Help? The Medical Journal of Australia, 184, S60-S64.
[30]
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
[31]
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
[32]
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
[33]
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
[34]
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
[35]
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
[36]
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
[37]
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
[38]
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
[39]
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
[40]
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
[41]
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
[42]
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
[43]
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
[44]
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
[45]
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
[46]
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
[47]
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
[48]
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
[49]
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
[50]
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.
[51]
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)
[52]
Dan, H., Uema, A. and Shinkai, H. (2010) Incident Report Saiko, Iryoanzen Kotohajima, Igakushoin. 21-34. (In Japanese)
[53]
Reason, J. (2000) Human Error: Models and Management. BMJ, 320, 768-770.
https://doi.org/10.1136/bmj.320.7237.768
[54]
NHS England (2015) Patients Safety Domain; Revised Never Events Policy and Framework. London.
[55]
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
[56]
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
[57]
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
[58]
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
