A Process Oriented Analysis Method for Medication Incidents

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  • 業務プロセスに着目した与薬事故分析手法の提案
  • ギョウム プロセス ニ チャクモク シタ ヨヤク ジコ ブンセキ シュホウ ノ テイアン

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Abstract

It is important for hospitals to tackle with malpractices in order to deliver safe medical services. Incident reports are collected to achieve its goal. Although, the number of accidents is not decreasing since hospitals deal with these accidents only by enhancement of checking or announcement of calling attention. Medication is administered under the fixed process. Therefore, it is effective to improve the process to prevent medical accidents by focusing on its work method. In this study, this concept is called "Process oriented thinking". This paper proposes an analysis method named POAM (Process Oriented Analysis Method for Medical Incidents) that medical staff can implement process oriented thinking. POAM utilizes the medication model and the viewpoint list. The medication model describes medication that "A nurse receives information, prepares objects and performs tasks." and it is used to grasp situations of incidents. The viewpoint list contains viewpoints to extract process factors that induce incidents. In addition, the analysis procedure with the analysis sheet and a format of incident reports are proposed. After the introduction of POAM to a hospital, medical staffs implement process oriented thinking and medical incidents are decreased.

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