Introduction
A critical perspective on IRL systems including the use of a systems perspective
Healthcare delivery and the national reporting system in Japan
Methods
Research design and settings
Data collection period
Semi-structured interviews
Non-participatory observations
Data analysis
Findings
Nurse | Doctor | Safety Manager | AHP | Pharmacist | Administrator | Total | ||
---|---|---|---|---|---|---|---|---|
Acute care | Total | 11 | 11 | 1 | 3 | 3 | 4 | 33 |
Those with patient safety role | 5 | 5 | 1 | 2 | 2 | 1 | 16 | |
Mental health | Total | 11 | 5 | 1 | 6 | 1 | 4 | 28 |
Those with patient safety role | 3 | 1 | 1 | 1 | 1 | 0 | 7 |
Type of meeting | |||||
---|---|---|---|---|---|
Total observations | Hospital-wide committee | Nursing-led safety meeting | Doctor-led meeting | Risk management meeting | |
Monthly | Monthly | Weekly | Monthly | ||
Acute Care | 20 | 4 | 3 | 13 | n/a |
Mental Health | 17 | 4 | n/a | 9 | 4 |
Organizational resources for handling incident data
“Actually, if you share it with another person and share what you do, I think that it will achieve more, but since the capacity is fixed, for example, though I did a Root Cause Analysis recently, I have not got around to summarizing it yet, as I have other things to do (…)” (Patient Safety Manager, AC)
Perceived effectiveness of IRL systems and risk perceptions
“Learning…there is quite a lot, I believe.” (Senior Nurse, AC)“After all, I think it’s about raising awareness of that risk as a whole (in the team).” (Nurse, MH)
“There are many people who write abstract causal factors for adverse events such as the end of the night shift and the lack of concentration, so I wonder what to do? (…) so the quality of reports is not always useful for my work.” (Psychiatrist, MH)“If the person wasn’t there when an adverse event happened, and informed of that later, I believe it (the effectiveness) depends on his/her attitudes to work” (Senior nurse, AC).
“It doesn't work at all. Oh, we shouldn’t say it doesn’t work at all, should we? (...) I don't think it's very effective.” (Senior consultant, AC)
“The input system is so complicated that it takes a lot of time. I think it should be simplified a little more. It's pretty hard to understand as well.” (Junior doctor, AC)
Corrective measures and systems approach in team discussions
“Measures are not coming out of the PSO, but rather, staff on the wards are often asked to come up with their own measures (…) And then it’s like, we at the bottom rank don't know what actually happened or was implemented.” (Senior doctor, AC)“We created our own internal incident discussion mechanism in the pharmacy department only, and each individual writes a monthly report about cases based on his/her observation, using double checking, and proposes countermeasures, etc.” (Pharmacist, MH)
Acute Care | Mental Health | |
---|---|---|
Exploration of possible causes | Vascular injury due to catheterization: brief exchange of viewpoints regarding complications of catheter manipulation | Missed information around food allergy: lack of communication between the nutrition department and the ward |
Consideration of systems problems | Cerebral infarction after Coronary Angiography (CAG): unclear lines of responsibility in the process of obtaining informed consent and describing the risk of complication deriving from CAG | Patient’s unplanned entry to electroconvulsive therapy: miscommunication between different units |
Critiquing of hypothesized causes | Very little discussion, with some exceptions | Not observed |
Seeking further information about the incident | Not much discussion, apart from questions as to subsequent actions made by a doctor involved in the case, and the relevant electronic medical records | Follow-up information requested for cases where the information about how incidents occurred was not complete |
Factors shaping the management of IRL systems
Professional boundaries
“When problems about medical equipment are reported by a nurse, it is only when the patient is actually harmed. Preventive measures can only be provided if we find the problems ourselves before that report arrives. Even if the nurse wrote a near-miss report, it will only be dealt with at ward level and will not come up to us. These issues need to be sorted out”. (Medical technologist, AC)
“Basically, the largest professional group among us, clinical staff, is nurses, and if nurses lead and do patient safety thoroughly, just like a mother-child relationship, a nurse like a mother can tell off a doctor like a child, saying ‘no, doctor, please do it this way’. I think that’d be the best way." (Senior doctor, AC)
Dealing with psychological burden of reporting incidents
“It might be a little embarrassing to hear your incident report being discussed in a forum. For example, people must be thinking ‘Wow, he's making such an error still into his second year!’" (Junior doctor, AC)
“Rather, I report when something happens, and this I do also for the purpose of protecting myself.” (Junior doctor, AC)
Leadership and educational approach
“I think experience matters…I tell my current junior staff ‘I used to wonder why I made that error, I had to write my name, like a great criminal investigation, I had to report, I felt like a criminal, I hated it. You may feel like that now when you report, but this will become your own learning and help you, so if you have an incident, you can make it your own strength.’” (Senior nurse, AC)“It is not established as a system as such, but it is a human fortress. As the trainees spend more time with patients than I do (…) I do not rush and listen to patients' complaints in the first instance, but send the trainees to listen. If they come back with the message that the patient requested the person in charge, then I will go and take the responsibility… it is a multi-layered, problem-solving (training) system.” (Senior doctor, AC)
Compatibility of patient safety with patient-centered care
“There were several times when I felt like making a manual would become the end in itself (…) so I feel there is a little bit of danger that we could end up making a manual for more manuals … protocolization of care.” (Doctor, MH)
“After all, it will be more useful thinking about medical safety if we can do home visits and such like in the future at our own discretion, rather than being stuck in a hospital environment (…) I don't think it is necessary to be excessively nervous about patient safety events (in the hospital), and it would be good to see a step being taken towards home visits or medical care in the community (...).” (Senior doctor, MH)