Study on the contents and utilization of the reports of serious adverse event by in-hospital patient safety committee

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  • Fujita Shigeru
    Department of social medicine, Toho university school of medicine
  • Ito Shinya
    Department of social medicine, Toho university school of medicine All Japan hospital association
  • Yoshida Ai
    Department of social medicine, Toho university school of medicine All Japan hospital association
  • Iida Shuhei
    All Japan hospital association
  • Nishizawa Hirotoshi
    All Japan hospital association
  • Hasegawa Tomonori
    Department of social medicine, Toho university school of medicine

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Other Title
  • 重大な医療事故に対する院内医療事故調査の報告書内容と活用についての検討
  • ジュウダイ ナ イリョウ ジコ ニ タイスル インナイ イリョウ ジコ チョウサ ノ ホウコクショ ナイヨウ ト カツヨウ ニ ツイテ ノ ケントウ

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Abstract

<p>In case of serious adverse event, in-hospital patient safety committee is expected to play a principle role in investigating the cause of the event and in developing preventive methods. No standard method as to the analysis or the contents of the report has been established, and it is difficult for other hospitals to utilize the results of the investigation in preventing similar events. The aim of this study is to reveal the present situation of recorded items in the report, and the means to make the reports available to other hospitals.</p><p>All member hospitals of the All Japan Hospital Association and stratified samples of non-member hospitals were requested to answer the questionnaire in September, 2011. The questionnaire included questions about the experience of serious adverse events and recorded items in the reports. By using cluster analysis, the reports were classified based on the recorded items.</p><p>The response rate was 32.4% (1,261/3,890). Among them, 34.9% experienced adverse events during past 3 years. The reports were classified by its' characteristics of description items into 2 types；cluster A (n=177) and cluster B (n=100). In comparison with cluster B, cluster A had a tendency to keep parties' anonymity, to receive support from external experts for the investigation and to record important items, which would affect the quality of the report, such as the cause of accident and preventive methods. In addition, 58.2% of hospitals answered that the item of “an evaluation method regarding the state of implementation and the effectiveness of preventive method” was not needed in the report.</p><p>To encourage “the reports intended to publicize” with “an evaluation method regarding the state of implementation and the effectiveness of preventive method” might be effective for other hospitals to utilize the results of in-hospital investigation.</p>

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