A study on document style of medical safety incident report for latent factors extraction and risk- assessment-based decision making

In order to prevent future medical troubles, incident cases are collected. From the collected data, the causes/factors are analyzed, and prevention measures are proposed. However, in many medical spots, quality of data obtained from incident report documents is very low. So, analysis of factors becomes insufficient, and many prevention measures cannot defeat latent factors. Therefore, we intend to propose an incident report support system. This system builds on three foundations. First is an incident report form to easily identify factors that lead to accidents. Second is a method to decide priority of an incident by analyzing risk from not only a subjective viewpoint but also an objective viewpoint. Third is a matrix of measures to prevent troubles, as well as to plan measures for even those lacking knowledge or experience and to reduce time and burden in considering measures. We developed such an incident report support system application running on a PC. Users only have to click items they think are relevant. Once items are specified, the application processes them and gives feedback based on the items. 21 out of 23 safety managers in 5-units said that they would want to use this application, which has feedback on evaluating priority of an incident and listing radical measures to prevent troubles. By using an incident report support system, safety activity can expand beyond not only safety managers but also on site medical staffs. With such a support system, staffs can come together and cope with safety activity, which is expected to lead to safety improvements.