Sample characteristics
Table 1 shows the frequency and percentage of case reports by several factors. The highest number of incidents was reported from January to March (n = 33, 38.8%), and the second highest was during the period October to November (n = 21, 24.7%). Almost all cases reported occurred in the daytime on weekdays: 92.9% (n = 79) of incidents occurred on weekdays. Most direct-care incidents occurred from 2:00–3:00 pm (n = 11, 30.6%), while most indirect-care incidents occurred from 10:00–11:00am (n = 14, 31.8%). The highest incident rates occurred in outpatient units (n = 23, 27.1%) and examination or operating rooms (n = 12, 14.1%). There were no significant differences in incident characteristics between direct care and indirect care.
Incident report types
Fourteen out of the 85 cases (16.5%) involved patient misidentification. Table 2 shows the incident report types and how these differed for direct-indirect care. The percentage of patient misidentification for indirect care (n = 12, 26.1%) was significantly higher than that for direct care (n = 2, 5.1%; p = .017). Furthermore, the number of incidents involving medication for direct patient care was more than twice that of indirect care (p < .001).
Incident reports of direct impact on patient care
Thirty-nine out of 85 cases (45.9%) were determined to have a direct impact on patient care. They are presented by theme in Table 3. Four categories of themes of direct-care incidents were extracted: drug prescriptions (n = 24, 61.5%); system administration, information, and documentation (n = 7, 17.9%), inquiry (n = 5, 12.8%), and other (n = 3, 7.7%). For drug prescriptions, these cases occurred in situations such as a doctor asking a clerk to enter a medication order into electronic health records on the doctor’s behalf.
When the staff member was asked by a doctor to type a drug order, the staff member mistyped the amount of Digoxin (digoxin is used to treat heart failure). (No. 6)
Nine out of 24 cases consisted of mistakes in prescription information. For example, a reception clerk did not ask whether a patient was taking a particular medicine.
Prior to the patient’s exam, the staff had asked the patient to stop taking the drug, but the patient didn't say anything, so the staff didn't specifically ask. On the day of the patient's exam, the patient was taking the medication. (No. 82)
The next most common themes of indirect impact on patient care were system administration, information, and documentation. Three out of seven cases were related to communication errors with another department.
When I made a phone call regarding the preparation of chemotherapy, I said “today's treatment will be done,” but it was wrong. I had to correct myself and say“today's treatment was canceled.” (No 72)
Mistakes in preparing exam documents and hospital ambulance management errors occurred in two cases. In Japan, several large hospitals have their own ambulances, and these ambulances are managed and operated by hospital staff; accordingly, two cases related to ambulance equipment failure were reported.
Five out of the 39 (12.8%) direct impact incidents were inquiry errors. Inquiry errors were usually directly related to treatment by a physician, such as before hemodialysis or a prescription-related weight measurement (3 cases). In addition, there were two errors that resulted from a check of the patient’s medical device records or the entry of data into an electronic medical chart on behalf of a doctor (2 cases). In the case of an anticancer drug, a serious accident may have occurred if not detected in advance, as in the following case.
The staff member measured the patient's height and weight, but transposed height and weight in the electronic medical chart. The doctor prescribed the patient's anti-cancer agent based on this mistyped record. (No. 68)
Incident reports of indirect impact on patient care
Forty-six out of 85 (54.1%) cases represented indirect impact on patient care, as shown in Table 4. These included five categories: system administration, information, and documentation (n = 22, 47.8%): reception (n = 9, 19.6%), reports of co-workers’ errors (n = 8, 17.4%); accounting (n = 6, 13.0%); and other (n = 1, 2.2%). The category system administration, information, and documentation included misidentification of information and/or documents (e.g., fax number, patient profile, etc.) and database system errors (e.g., hospital electronic records, accounting management system).
The staff put an incorrect blood type seal in the patient's chart. (No. 80)
Hospital administrative staff frequently call and talk directly to patients through reception or accounting. In the reception category, examples of reported incidents include communication (four cases), misidentification of exam documents and administration of patient information (four cases), and miscommunication of forthcoming treatment (one case).
The patient talked with administrative staff about having an MRI exam. The staff said it depended on the situation, but the patient came to the hospital because he thought he could have the MRI examination that day. (No. 6)
The third most common indirect impact on patient care was a co-worker’s error, with eight reports; doctor’s error was involved in five cases; nurses or nutritionists were report subjects in only one case. In accounting processes, there were six cases; errors in medical expenses occurred in four cases, and prescription accounting and misidentification of a patient’s ID card each occurred once.