Utilization of a Voluntary Reporting System in Quantitative Risk Assessment for Medical Tasks in a Hospital Settinga-with Special Reference to Tasks Done by Nurses

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概要

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• Adverse events in hospitals are a world-wide concern. To develop a tool for quantitative risk assessment of medical error, human reliability analysis was applied to incident reports from a prospective cohort study in a hospital. 374 nurses in a tertiary-care hospital of 670 beds joined this study. Numbers of tasks, classified into 170 items, were actually measured by nurses during three weekdays and one weekend. The total number of tasks per year was found to be about 13.2 million. 1,030 incidents were reported over a year. The gross failure rate for tasks was estimated to be -10^-4. The relative risk for failure rates in midnight and night shifts was 2-4 times greater than in dayshifts. When the failure rate for a patient category of ages 15 and 64 yr old was taken as a standard, the relative risk of failure was about 200 times greater in a patient category of problematic behavior and 90 times greater in patient categories of clouding of consciousness and postsurgical conditions. Failure rates for individual tasks were in the range of 10^-5 to 10^-3: the tasks with the highest failure rate were prevention of problematic behavior (2.32 ★ 10^-3), safeguards against falls (1.47 ★ 10^-3), intramuscular injection (1.30 ★ 10^-3) and subcutaneous injection of insulin (9.82 ★ 10^-4). The present study revealed two potential risks: occasional tasks with high failure rates and patient categories with small numbers of patients with high failure rates. The present protocol enabled us to conduct quantitative risk assessment on occupational health for medical workers.

• 社団法人日本産業衛生学会の論文

著者

• Koizumi A

  Kyoto Univ. Kyoto Jpn

• Aoki Kunio

  Department Of Health And Environmental Sciences Kyoto University Graduate School Of Medicine

• Koizumi Akio

  秋田大学 衛生

• Koizumi Akio

  Department Of Hygiene Yamaguchi University School Of Medicinemedicine

• INOUE Kayoko

  Department of Health and Environmental Sciences, Graduate School of Medicine, Kyoto University

• Koizumi Akio

  Department Of Health And Environmental Sciences Graduate School Of Medicine Kyoto University

• YOSHINAGA Takeo

  Department of Health and Environmental Sciences Graduate School of Medicine, Kyoto University

• HIROSAWA Iwao

  Department of Hygiene,Yamaguchi University School ofMedicine

• TANI YOSHIO

  Seibo Jogakuin Junior College

• HIROSAWA Iwao

  Kansai University of Welfare Sciences

• Yoshinaga Takeo

  Department Of Health And Environmental Sciences Graduate School Of Medicine Kyoto University

• YATSUDUKA Miki

  Department of Human Science and Fundamental Nursing, Toyama Medical and Pharmaceutical University Sc

• Koizumi Akio

  Department Of Health And Environmental Science School Of Public Health Kyoto University

• Hatai Ikuno

  Department Of Food And Nutrition Kyoto Women's University

• Inoue Kayoko

  Department Of Health And Environmental Sciences Kyoto University Graduate School Of Medicine

• Yatsuduka Miki

  Department Of Human Science And Fundamental Nursing Toyama Medical And Pharmaceutical University Sch

• Hirosawa I

  Yamaguchi Univ. School Of Medicine Ube Jpn

• Hirosawa Iwao

  Department Of Hygiene Yamaguchi University School Of Medicine

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