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

质量管理视角下医疗事故预防研究

基本信息

批准号：
14580491
负责人：
MUNECHIKA Masahiko
金额：
$ 2.56万
依托单位：
Waseda University
依托单位国家：
日本
项目类别：
Grant-in-Aid for Scientific Research (C)
财政年份：
2002
资助国家：
日本
起止时间：
2002 至 2003
项目状态：
已结题

来源：
https://kaken.nii.ac.jp/en/grant/KAKENHI-PROJECT-14580491/
关键词：
Medication error Quality Management Error-Proofing Analysis Method Reporting System Accident Prevention

项目摘要

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.

医疗事故的形式多种多样。在任何医院，用药错误和跌倒在事故数量中排名都很高。用药错误主要表现为用药数量或种类错误、漏服药物等。跌倒是从床上或轮椅上摔下来，走路时摔倒。这两类事故占医疗事故总数的70%，减少这两类事故的发生将产生巨大的影响。本研究的目的是减少这两类事故的发生，在2002年会计年度，主要分析了用药错误的问题。从标准化用药过程与实际工作之间的关系的角度对事故报告进行审查，并确定事故原因。列出了对策。医疗人员和研究者之间讨论了差错预防的方法，如防差错、差错检测和管理系统，如过程控制、变更控制和设备控制。根据分析结果，提出了一种事故报告分析方法和报告系统。并将所采取的措施应用于实际生产过程，验证了其预防事故的效果，并对2003财年的坠落问题进行了分析。评估疾病的状况和患者的身体特征。收集了坠落和未坠落的数据。将定量II应用于数据，并澄清了两组之间的区别。根据调查结果提出护理计划和计划对策表，验证了减少事故发生的效果。也对用药错误进行了调查。建立了推进标准化的方法论和规划防错对策。