Incident reports with direct impact on patient care
Thirty-nine out of 85 cases (45.9%) involved direct care to patients. These are presented by themes in Table 1. For direct-care incidents, four categories of themes 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%). Drug prescription cases occurred in situations such as a doctor asking a clerk to enter a medication order into electronic health records on their 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 still on the medication. (No. 82)
The next most common theme for direct impact on patient care was 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 was supposed to 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, which 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 care 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). Additionally, in two cases, errors resulted from checking the patient’s medical device records or entering data into an electronic medical chart on behalf of a doctor. The following case illustrates how a serious accident may have occurred if a mistake with an anticancer drug had not been detected in advance.
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 with indirect impact on patient care
Forty-six out of 85 (54.1%) cases represented an indirect impact on patient care, as shown in Table 2. 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 of 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 they thought they could have the MRI examination that day. (No. 6)
The third most common type of incident report involving indirect care was a co-worker’s error (eight cases); doctor’s error was involved in five cases and 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.
Differences in case reports between direct and indirect care
Table 3 shows the frequency and percentage of case reports by various factors. The highest number of incidents was reported from January to March (n = 33, 38.8%), and the second highest was form October to November (n = 21, 24.7%). Almost all reported cases occurred in the daytime on weekdays (n = 79, 92.9%). Most direct-care incidents occurred from 2:00–3:00pm (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%).
Fourteen out of the 85 cases (16.5%) involved patient misidentification. Table 4 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 higher than that for direct care (n = 2, 5.1%). Furthermore, the number of incidents involving medication for direct patient care was more than twice that of indirect care.