Development and evaluation of incident reporting system in Japanese home visit nursing agencies

2022 Fiscal Year Final Research Report

• Project/Area Number: 19K19746
• Research Category: Grant-in-Aid for Early-Career Scientists
• Allocation Type: Multi-year Fund
• Review Section: Basic Section 58080:Gerontological nursing and community health nursing-related
• Research Institution: Keio University
• Principal Investigator: YAMAMOTO-TAKIGUCHI Natsuki 慶應義塾大学, 看護医療学部(藤沢), 助教(有期・研究奨励) (80835851)
• Project Period (FY): 2019-04-01 – 2023-03-31
• Keywords: 訪問看護 / 患者安全 / インシデントレポートシステム / 心理的安全性

Outline of Final Research Achievements

(1) From the interviews after the trial of the prototype system, there were opinions that the system can be accessed from any location and that the reports are easy to make because the items are mainly selective. On the other hand, some respondents requested that the quality of the descriptive part of the case summary (descriptive type) be assured to a certain extent in order to grasp the details of the accident.
(2) There was a tendency for homecare agencies (HCAs) with higher psychological safety of staff to regularly post-incident reviews were conducted (p=0.057).
On the other hand, 20.5% of the HCAs regularly conduct post-incident review, and the highest proxy learning need of the homecare nurses was "recurrence prevention measures reviewed after an accident or other incident" (78.2%).

Free Research Field

在宅看護

Academic Significance and Societal Importance of the Research Achievements

１）施設横断的なシステム試用から、オンラインでの報告形態、選択式の報告項目などの利便性・妥当性が示唆されるとともに、記述内容の質の担保に関する課題が明確化された。
２）国内で初めて、看護師の心理的安全性が高い訪看STほど、定期的に事後検討が検討される傾向が示された。また定期的な事後検討を行う訪看STは限定的であり、他訪看STが検討した再発予防策への代理学習ニーズが高いことから、訪看ST内での事故等の情報活用が不十分である可能性が示唆された。より実効性の高いシステムのために、事故等からどのように組織学習が展開されたかの実践事例や実践手引きに関する参照機能の実装の重要性が示された。