From: Patient safety education at Japanese medical schools: results of a nationwide survey
Ā | Ā | Public (N=31) | Private (N=16) | Total (N=47) |
---|---|---|---|---|
Ā | Ā | n (%) | n (%) | n (%) |
Hospital safety management | Ā | Ā | Ā | |
Ā | Institutional near-miss/ adverse event reporting | 22 (71.0) | 11 (68.8) | 33 (70.2) |
Ā | Committee for patient safety | 21 (67.7) | 10 (62.5) | 31 (66.0) |
Ā | Department of patient safety | 18 (58.0) | 10 (62.5) | 28 (59.6) |
Ā | Principles of patient safety | 18 (58.1) | 8 (50.0) | 26 (55.3) |
Ā | Patient safety officer | 20 (64.5) | 6 (37.5) | 26 (55.3) |
Ā | Staff orientation for patient safety | 16 (51.6) | 6 (37.5) | 22 (46.8) |
Ā | Investigation committee for adverse events | 13 (41.9) | 5 (31.3) | 18 (38.3) |
Ā | Reporting to Japanese Council for Quality Health Care [10] | 7 (22.6) | 2 (12.5) | 9 (19.1) |
Ā | Patient relations (patient feedback) | 6 (19.4) | 3 (18.8) | 9 (19.1) |
Medical error theory | Ā | Ā | Ā | |
Ā | Human factors | 25 (80.6) | 13 (81.3) | 38 (80.9) |
Ā | Theories and models (Swiss Cheese Model, Heinrichās Law) | 25 (80.6) | 11 (68.8) | 36 (76.6) |
Ā | System factors | 21 (67.7) | 12 (75.0) | 33 (70.2) |
Ā | Work environment | 19 (61.3) | 7 (43.8) | 26 (55.3) |
Practical safety | Ā | Ā | Ā | |
Ā | Reporting near-miss/ adverse events | 22 (71.0) | 12 (75.0) | 34 (72.3) |
Ā | Verifying patient identity ā | 24 (77.4) | 8 (50.0) | 32 (68.1) |
Ā | Double-checking | 20 (64.5) | 7 (43.8) | 27 (57.5) |
Ā | Communication of near-miss/ adverse events internally | 18 (58.1) | 7 (43.8) | 25 (53.2) |
Ā | Identifying risks and developing prevention strategies ā | 18 (58.1) | 5 (31.3) | 23 (48.9) |
Ā | Standardizing procedures ā | 19 (61.3) | 3 (18.8) | 22 (46.8) |
Ā | Fail-safe systems | 16 (51.6) | 5 (31.3) | 21 (44.7) |
Ā | Object pointing with verbal confirmation ā | 18 (58.1) | 2 (12.5) | 20 (42.6) |
Ā | Reading back verbal orders ā | 17 (54.8) | 1 (6.3) | 18 (38.3) |
Ā | Modifying drug names ā | 14 (45.2) | 2 (12.5) | 16 (34.2) |
Ā | Patient cooperation ā | 12 (38.7) | 2 (12.5) | 14 (29.8) |
Ā | Concept of fool-proof | 11 (35.5) | 3 (18.8) | 14 (29.8) |
Ā | Appropriate documentation of adverse events | 11 (35.5) | 2 (12.5) | 13 (27.7) |
Ā | Coherence of documentation of adverse events | 10 (32.3) | 2 (12.5) | 12 (25.5) |
Ā | Confirming orders ā | 9 (29.0) | 0 (0.0) | 9 (19.2) |
Error analysis | Ā | Ā | Ā | |
Ā | Root Cause Analysis | 9 (29.0) | 2 (12.5) | 11 (23.4) |
Ā | Software, Hardware, Environment, and Liveware (SHEL) Model ā | 7 (25.6) | 0 (0.0) | 7 (14.9) |
Ā | 4M-4E | 6 (19.4) | 0 (0.0) | 6 (12.8) |
Ā | Failure Mode and Effect Analysis (FMEA) | 1 (3.2) | 1 (6.3) | 2 (4.3) |
Management of adverse events | Ā | Ā | Ā | |
Ā | Patient communication | 14 (45.2) | 9 (56.3) | 23 (48.9) |
Ā | Reporting unnatural deaths to the police | 13 (41.9) | 8 (50.0) | 21 (44.7) |
Ā | Formulating prevention strategies | 15 (48.4) | 6 (37.5) | 21 (44.7) |
Ā | Emergency protocols | 14 (45.2) | 6 (37.5) | 20 (42.6) |
Ā | Apology | 13 (41.9) | 7 (43.8) | 20 (42.6) |
Ā | Documentation | 12 (38.7) | 6 (37.5) | 18 (38.3) |
Ā | Hospital investigation | 11 (35.5) | 5 (31.3) | 16 (34.1) |
Ā | Definition of terms | 12 (38.7) | 4 (25.0) | 16 (34.1) |
Ā | Transparency/public disclosure | 9 (29.0) | 5 (31.3) | 14 (29.8) |
Ā | Preservation of evidence | 9 (29.0) | 4 (25.0) | 13 (27.7) |
Ā | Recommending autopsy | 8 (25.8) | 4 (25.0) | 12 (25.5) |
Ā | Analyzing medical errors | 7 (22.6) | 5 (31.3) | 12 (25.5) |
Ā | Management of medical personnel involved in the adverse event | 9 (29.0) | 2 (12.5) | 11 (23.4) |
Ā | Sharing adverse events with other institutions for learning | 6 (19.4) | 4 (25.0) | 10 (21.3) |
Autopsy | Ā | Ā | Ā | |
Ā | Clinical autopsy | 18 (58.1) | 12 (75.0) | 30 (63.8) |
Ā | Judicial autopsy | 18 (58.1) | 10 (62.5) | 28 (59.6) |
Ā | Administrative autopsy | 11 (35.5) | 8 (50.0) | 19 (40.4) |
Ā | Model Project for healthcare-associated patient deaths [15] | 8 (25.8) | 3 (18.8) | 11 (23.4) |
Legal and societal responsibilities | Ā | Ā | Ā | |
Ā | Civil liabilities | 26 (83.9) | 12 (75.0) | 38 (80.9) |
Ā | Criminal prosecution | 25 (80.6) | 12 (75.0) | 37 (78.7) |
Ā | Societal responsibilities | 20 (64.5) | 11 (68.8) | 31 (66.0) |
Ā | Administrative penalties on the individual | 19 (61.3) | 10 (62.5) | 29 (61.7) |
Ā | Administrative penalties on the institution/system | 11 (35.5) | 7 (43.8) | 18 (28.3) |