A Study On The Method Of Designing

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A STUDY ON THE METHOD OF DESIGNING KIKEN YOCHI TRAINING SHEETS (HAZARD PREDICTION TRAINING SHEETS) IN MEDICAL SERVICE

Chisato KAJIHARA1 Masahiko MUNECHIKA2 Masaaki KANEKO3

1Waseda University, Japan, JSQC,

2Waseda University, Japan, JSQC,

3Waseda University, Japan, JSQC,

ABSTRACT

Safety procedures are carried out in hospitals to prevent medical incidents and to provide high-quality medical services. Many hospitals have introduced Kiken Yochi Training (KYT) as one of these safety procedures; KYT involves training to improve the ability to identify hazards by discussing the hidden hazards depicted in the KYT sheet, which demonstrates the workplace and working conditions. However, there is no established method to make KYT sheets. This study proposes a method of designing KYT sheets for use in the prevention medical incidents.

In order to effectively implement KYT for preventing medical incidents, the incidents to be represented on the KYT sheet should be determined according to the number of occurrences and the incident factors should be properly represented on the KYT sheet. Additionally, the answer to the KYT sheet is necessary for evaluating the ability to identify hazards. Therefore, 30 medication incidents in hospital A were analyzed as follows: counting the number of occurrences, arranging factors by using the P-mSHELL model, determining how to represent factors on the KYT sheet, and analyzing unsafe behavior and the effects of incidents for preparing a hazard-story. In addition, the results of analysis were arranged in an incident list to reflect the results on the KYT sheet.

This study proposed the following design method by utilizing the incident list; (1) deciding the incidents to be represent on the KYT sheet, (2) preparing hazard-story for the answer to the KYT sheet, (3) setting the work conditions for the KYT sheet and taking photographs, and (4) establishing condition-setting. By using the proposed design method, the KYT sheets outlining the occurrence of medical incidents can be prepared. KYT was executed using KYT sheets made according to the proposed method. The result of this study revealed an improved ability to identify hazards.

Key Words: medical safety, medication incidents, KYT (Hazard Prediction Training)

INTRODUCTION

Quality and safety in the medical service have recently come under increasing public scrutiny. Therefore, it is necessary for hospitals to provide a high-quality healthcare service. Furthermore, as a consequence of a revision of the payment system for medical service in Japan, many new nurses are now being employed in hospitals. However, the employment of many new nurses who do not have the requisite nursing knowledge and skills has let to an increase in the number of medical incidents. Medical incidents also occur as a result of the careless actions of intermediate and senior nurses. Therefore, it is essential that safe procedures that lead to the prevention of medical incidents are conducted in hospitals.

Many hospitals have introduced Kiken Yochi Training (KYT), or Hazard Prediction Training. KYT is a training method designed to improve the ability to identify hazards by discussing the hidden hazards depicted in KYT sheets that show the workplace and work conditions. However, because there is no standard procedure for producing KYT sheets, creating such sheets is dependent on the nurses themselves. Therefore, effective KYT for the prevention of medical incidents is typically not executed. In order to conduct effective KYT, it is necessary to produce KYT sheets in order to educate on various incident factors.

The purpose of this study was to propose a design method for KYT sheets to be use for educating on the prevention of medical incidents.

INVESTIGATING THE CURRENT SITUATION

The KYT Method

KYT sheets are used to show the workplace and work conditions, to promote discussion on the hazardous factors in the workplace and in work conditions (unsafe conditions and unsafe behavior that may lead to medical incidents), and to stimulate discussion on the phenomena (type of incidents) that may arise from such factors. The sheets also enable information on hazards to be shared among members of the workforce. Finally, they provide a focus for meetings convened to find solutions to hazards. Thus, KYT is considered as a training tool designed to improve the ability to notice hazards and to solve problems. The following points summarize the KYT procedure.

[1]  Understanding the actual situation: Discuss the hazards depicted in the KYT sheet. When members discuss the hazards, they relate a “hazard-story”; a “hazard-story” describes the relationship between hazardous factors, unsafe behavior that may arise from such factors, and the incident phenomena that may arise from unsafe behavior.

[2]  Determining the hazard points: Select the hazard that members should solve from the hazards found in step [1].

[3]  Establishing measures: Establish measures to solve the hazards selected in step [2] - as many as possible.

[4]  Setting goals: Select the measures that members have to adopt from the measures that were established in step [3].

The Current Problem with KYT

It is necessary to understand the current problem with KYT in order to propose a design method for KYT sheets. Therefore, literatures on the KYT conducted in the industrial world and in medical service were investigated. As a result, there are literatures gathered existent KYT sheets. However, a specific design method for KYT sheets has not been established. Due to this problem, it is not possible to produce KYT sheets that reflect actual incidents situations. In hospital A where KYT was introduced, an interview was conducted with nurses who compiled KYT sheets. It was found that when the nurses produced the KYT sheets, they defined the workplace and the work conditions in the KYT sheet without considering medical incidents. A comparison of the workplace and the work conditions were depicted in the KYT sheets by such way with actual incident situations occurred in hospital A was conducted. As a result, the incidents didn’t occur in the work condition depicted in the KYT sheets. Therefore, current KYT sheets do not provide education on incident factors.

An additional problem was that of making the answer to the KYT sheets dependent on nurses. There were no guidelines for identifying hazards and the method for evaluating the ability to identify hazards. Therefore, it has not been possible to confirm whether KYT is effective or not. Table 1 shows the investigation results.

Table 1. The current problem with KYT in the medical service

Current problem with KYT / Causes of the problem
KYT sheets that are based on incidents situations are not produced. Therefore, effective KYT for preventing medical incidents cannot be executed in each hospital. / (1)The incident to be represented on the KYT sheet cannot be decided.
(2)The incident factors cannot be reflected as they are normally observed.
A means by which evaluate the ability to identify hazards has not been established. / (3)The answer to the KYT sheets is not based on evidence.

In order to execute effective KYT, it is necessary to establish a design method for KYT sheets that addresses the causes of the problem (1) ~ (3) shown in table 1.

PROPOSING A METHOD OF DESINING KYT SHEETS FOR PREVENTING MEDICAL INCIDENTS

Considering the Requirements of KYT

If a design method for KYT sheets that solves the problem shown in table 1 is established, KYT sheets for preventing medical incidents can be produced and effective KYT will be executed. Therefore, the requirements of KYT for solving the causes (1) ~ (3) were considered. Requirements numbers (1) to (3) correspond to causes numbers (1) to (3) shown in table 1.

(1) The incident depicted in the KYT sheet is chosen according to the maximum number of occurring incidents.

(2)-1 The incident factors reflected in the KYT sheet are determined.

(2)-2 The determined incident factors are correctly reflected in the KYT sheets.

(3) The answer to KYT for evaluation the ability to identify hazards is made.

The Incidents as Objects of KYT

In order to fulfill requirements (1) ~ (3), when KYT sheets are produced, the incidents should be referred to. By way of demonstrating the procedure, medication incidents that occurred in hospital A will be analyzed and the result of the analysis will be utilized for producing KYT sheets. However, many types of incidents occur in hospitals and KYT is not an effective means of educating on all types of incidents. For example, KYT is not suited to the educating on the prevention of incidents that occur through a failure to follow the standard practice. For reducing such incidents, teaching standard practice is more effective.

The aim of executing KYT is not teaching standard practice but improving the ability to notice hazards. In this paper, the incidents as objects of KYT are the careless incidents that nurses (who have knowledge and skills) caused, even though they followed standard practice. Therefore, 30 incidents as objects of KYT (over a period of 9 months) are selected from the incidents that occurred in hospital A, and these are analyzed.

Analysis of Medication Incidents and Arrangement of the Results

In order to fulfill the requirements shown above, the medication incidents as objects of KYT were analyzed according to following (1) ~ (3) analysis steps. By analyzing case A as an example, the analysis steps are explained.

[A case example of medication incidents as objects of KYT]

Patient A was placed on 2 drips (medicine X and medicine Y) the speeds of which were the same (20m/h). The instructions [change the speed of the main drip (medicine X) from 20ml/h to 60ml/h] was written on a prescription for patient A. Ns. B, who took care of patient A, changed the speed of the drip without confirming the route of the drip before taking a rest. However, Ns. B changed the speed of the wrong drip (medicine Y) from 20ml/h to 60ml/h.

(1) Classifying the medication incidents by similar incidents and counting the number of incidents

A detailed investigation of every medication incident clearly revealed that similar incidents have often occurred. Therefore, the medication incidents that occurred in hospital A can be classified by similar incidents. By classifying the incidents, the number of such incidents can be counted and education for preventing the incidents can be efficiently executed according to the maximum number of occurring incidents.

Medication incidents arise from certain factors. In this paper, the incidents that have the same incident phenomena and same incident factor are defined as similar incidents. When the phenomena of an incident and the incident factor were identified, this study utilized “error modes,” which can represent all errors occurring in a segment of an operation known as a “work element” (Nakajo et al., 1985), and “error factors,” which can represent all causes of medication incidents (Ozaki et al., 2005). The error mode and error factor of case A were “mistake in choice” and “similar appearance or name,” respectively.

In addition, this study classified medication incidents into 9 similar incidents by combining error modes with error factors and counting the number of medication incidents. The number of each similar incident is shown in table 2.

Table 2. Classification of medication incidents by similar incidents and the number of such incidents

Similar incident No. / Error modes / Error factors / Number
1 / Skipping / Scattered information on a prescription / 1
2 / imperfect work attendant on main work / 6
3 / depending on memory / 1
4 / work interruption / 1
5 / mistake in counting / repeating similar work / 1
6 / mistake in choice / multiple choices / 5
7 / similar appearance or name / 10
8 / mistake in perception / bias on knowledge and memory / 3
9 / similar appearance or name / 2
total / 30

(2)-1 Analyzing and arranging factors using the P-mSHELL model

An incident arises from certain factors. In order to conduct effect KYT for the prevention of incidents, it is necessary to produce KYT sheets for educating on all factors that induce an incident. If the factors reflected on the KYT sheet are arranged correctly, all of thee factors will be depicted on the KYT sheet.

Therefore, the factors were analyzed using the P-mSHELL model which was originally proposed for use in human factor engineering. The results obtained from analyzing case A are shown in table 3.

Table 3. The result of analyzing factors of case A using the P-mSHELL model

Items of the P-mSHELL model / Analyzed factors
Patient / none
Management / none
Software / none
Hardware / similar route of drip
Environment / condition before taking rest
Liveware (original) / Action by preconceived ideas, lack of confirming route,
lack of confirming a prescription
Liveware (surrounding) / none

By utilizing the P-mSHELL model, all incident factors can be analyzed. However, the items of the P-mSHELL model, for example, “Patient,” are abstract words. Consequently, if the factors are arranged by utilizing these items of the P-mSHELL model, it is not obvious which factors should be reflected on the KYT sheet. Therefore, the factors analyzed using the P-mSHELL model were classified by similar factors and the items of the P-mSHELL model were embodied. The specific items of the P-mSHELL model are shown in table 4.

Table 4. Items of the P-mSHELL model and specific items

Items of P-mSHELL / Specific items / Items of P-mSHELL / Specific items
Patient / Patient’s condition / Environment / Condition of working
Management / Observance of rule / Condition of nurses’ station
Software / Condition of a prescription / Scattered objects
Rule in hospital / Liveware(original) / Lack of knowledge
Way of working / Action by preconceived ideas
Order for patient / Lack of confirming
Hardware / Medical instrument / Psychological condition
Medicine / Liveware
(surrounding) / Lack of confirming
by more than one person
Lack of communication

By arranging the incident factors in terms of the specific items shown in table 4, the incident factors reflected in the KYT sheet can be clearly understood.