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