A Study on Prevention of Medical Accidents from the View Point of Quality Management

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There are various forms of medical accidents. In any hospitals, medication errors and fall rank high in the number of accidents. The medication errors are mistaking quantity or type of medicine, and omitting medication. The fall is falling off beds or a wheelchair, and falling in walking. These two types of accidents account for 70 percent of all medical accidents and large effects are estimated if the accidents are reduced. The purpose of the study is reducing the two types of accidents.In 2002 fiscal year, the issue of medication errors is mainly analyzed. The reports of accidents are examined from the view point of relation between standardized process of medication and actual work, and the causes of accidents are defined. Countermeasures are listed. Methodology of error prevention such as error-proofing, error detection and management systems such as process control, change control and equipment control are discussed between medical people and investigator. According to the results, a method of analyzing incident reports and reporting system are proposed. Some countermeasures are applied to actual process and their effects of accident prevention are verified.In 2003 fiscal year, the issue of fall is analyzed. The condition of a disease and physical characteristics of patients are assessed. The data of fall and no fall are collected. Quantification II is applied to the data and the distinction between two groups is clarified. Then nursing plan and a table of planning countermeasures based on the results are proposed and effects of reducing accidents are verified. The medication errors are investigated as well. The methodology of promoting standardization and planning countermeasures of error prevention are established.