2023 Fiscal Year Final Research Report
Strategies for collecting high-precision facts that contribute to medical near-miss/adverse event analysis: Establishing guides for writing incident reports
| Project/Area Number |
20K14985
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| Research Category |
Grant-in-Aid for Early-Career Scientists
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| Allocation Type | Multi-year Fund |
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| Review Section |
Basic Section 25010:Social systems engineering-related
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| Research Institution | Jichi Medical University |
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Principal Investigator |
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| Project Period (FY) |
2020-04-01 – 2024-03-31
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| Keywords | インシデントレポート / 医療安全 / 医療事故調査 / 事故再発防止 / 事故原因究明 / 安全教育 |
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| Outline of Final Research Achievements |
This study aimed to improve the accuracy of collecting fact information about medical incidents. First, indicators for accurately describing facts in the incident reports (IRs) were clarified, i.e., including the 5W1H and things they witnessed, itemizing events in chronological order and in short sentences with clear subjects. Next, it was tested whether the indicators contribute to the actual quality of IR. As a result, the resident IRs provided extensive information on patients, medications, medical devices, reporter’s action, post-incident response, and original operating procedures. The experiment also tested whether the indicators contribute to the fact-gathering interviews conducted with the parties based on the IRs. As a result, IR with indicators increased the number of questions by investigators to determine accident factors and extensive questions about man, machine, media, and management.
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| Free Research Field |
医療人間工学
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| Academic Significance and Societal Importance of the Research Achievements |
事故の再発防止に関する多くの研究は，原因追求・対策立案の手法に関するものである．これらは事実情報を十分に得たことを前提に分析される．現状の医療現場では事実情報が不十分なケースが多いが，その改善を目的とした研究はほぼ存在せず，本成果は学術的意義がある．また本成果により，1)事故当事者がIRを記載しやすくなり，事実収集の質と量が向上する点，2)事故調査者がIRを基に不明点を把握しやすくなり，事実収集のヒアリング精度と効率が向上する点，3)事実収集の効率が向上し，より多くのIRを有効活用できる点が期待される．本成果は他施設への汎用性も高く，医療全体の安全と質の向上に寄与し，社会的意義が大きい．
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