Analysis of medication incident for improvement of medication process

Abstract

Purpose. This study aims to develop a viewpoint list for the analysis of medication incidents since it is important for hospitals to tackle malpractice in order to deliver safe medical services. Incident reports were collected to achieve this goal. However, the number of accidents is not decreasing. In particular, medical incidents caused when nurses administer medication by injection or internally occur in many hospitals. Methodology/approach. A total of 513 incidents are analysed with the medication model to develop a viewpoint list to it make easier to extract direct error factors to develop countermeasures with questions. Each incident is stratified with the pattern described with the medication model. It was applied with 20 incidents to verify the effect. Findings. This method using the medication model and viewpoint list could detect error factors effectively. Research limitations/implications. The implementation of the revised viewpoint list to ward nurses is necessary since 20 incidents to verify the effect of the viewpoint list were analysed by the authors.

Keywords:

• patient safety
• incident analysis
• process oriented analysis

Acknowledgements

The authors would like to express their appreciation to the safety managers of Hospital A for disclosing the case information and for valuable discussions. A part of this study is supported by Grant-in-Aid for Young Scientists (B) in Grant-in-Aid for Scientific Research (KAKENHI).