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A STUDY ON PLANNING ERROR-PROOFING COUNTERMEASURES TO REDUCE MEDICATION INCIDENTS
Chen, Ru1, Masahiko MUNECHIKA2, Masaaki KANEKO3
1Waseda University, Japan, JSQC,
2 Waseda University, Japan, JSQC,
3 Waseda University, Japan, JSQC,
ABSTRACT
Medical accidents, which often occur in hospitals, are considered a social problem. In order to provide safe healthcare, incident reports are being formulated by most hospitals to identify a method to prevent errors in medical administration, especially in medication.
Considering the old proverb “to error is human,” it is important to establish a process of medical administration that can be easily executed by nurses. Therefore, many hospitals attempt to prevent medication incidents by improving their working methods. In this study, an error-proofing method is applied to reduce the incidents related to the working methods. The error-proofing method is a device that lowers the probability of human errors. It is adopted in various manufacturing processes, and it has been effective in preventing human errors. Although it is not exploited adequately in hospitals yet, many solutions have been proposed on the basis of experiences and ideas of analysts.
In order to simplify the process of planning error-proofing countermeasures, the following approaches are employed in this study: (1) extracting improvement objects from working methods by analyzing incidents; and (2) correlating the improvement objects with error-proofing solutions that should be adopted. Finally, these parameters are arranged in the form of a map and a list, respectively. Moreover, these tools are summarized as a procedure for analyzing the incidents and planning appropriate error-proofing countermeasures. Additionally, in this report, the result of the application of the proposed method in Hospital A is presented. In conclusion, the proposed procedure can be easily applied for planning error-proofing countermeasures.
Keywords: medication incidents, improvement objects, error-proofing, countermeasures
1. INTRODUCTION
Many hospitals attempt to prevent incidents by improving working methods since medical accidents are considered as a social problem. Nakajo et al. demonstrated that error-proofing countermeasures can effectively prevent incidents that are caused by inappropriate working methods (Nakajo et al., 2005). Error-proofing is a device that lowers the probability of human error. It is adopted in various manufacturing processes, effectively preventing human error. However, it is not well exploited in hospitals. Nevertheless, many solutions have been proposed based on analysts’ experiences and ideas. For example, in many hospitals, a staff member who makes a mistake will generally just be warned; consequently, the same medical incidents tend to occur again and again.
The purpose of this study is to propose a method for analyzing medical incidents and planning error-proofing countermeasures.
The terms “incident” and “mistake” used in this paper are defined as follows.
・Incident: difference between the plan and the fact
・Mistake: someone’s action that causes an incident
2. THE CONVENTIONAL STUDY AND THE APPROACH OF THIS STUDY
2. The Conventional Study
2.1.1 The Study of Kuribara et al.
Kuribara et al. proposed 25 “work elements” that are commonly performed in every hospital. A work element is defined as a segment of an operation, in which “a person focuses on a certain object and identifies/changes the condition of the object” (Kuribara et al., 2006). Examples of work elements are shown in Table 1.
Table 1 - Work elements in medication service processes (extract)
No. / Work elements in medication service processes1 / examine the patient
2 / select a suitable medicine
3 / make a decision with regard to the parameters
4 / prescribe a medicine
… / …
16 / determine the administration
17 / examine the patient’s condition before administration
18 / prepare the medicine and the material
19 / identify the patient to be administered
… / …
2.1.2 The Study of Ozaki et al.
Ozaki et al. extracted human errors and factors from 175 incident reports relating to the process of medication administration. These errors and factors were defined as “error mode” and “error factor,” respectively. They also proposed guidelines for planning error-proofing countermeasures against each error factor (Ozaki et al., 2005). The guidelines are shown in Table 2.
Table 2 - The guidelines for planning error-proofing countermeasures proposed by Ozaki et al. (extract)
Error-proofingsolutions
Error factors / Completely
Substitution / Partly
Substitution / Centralization
/Communization / Individualization
/Specialization / Accommodation
people do not
need to work / assist in a part of
the work’s functions / reduce the differences
and the change / make the differences
and the change clearly / make things which are suitable for people’s ability
scattered information / connect / visualization of
information
instruct and record / grouping
synchronization
centralization / rouse attention
individualization / portable
immobilization
dependence on
memory / regularize / rouse attention / portable
to reduce the amount and time of memory
interruption of
the work / remove the
interruption
… / …
format of the
display of
information / mechanization / sample and cage / … / express attention
clearly
Identification / …
resemblance of name / …
… / …
However, since “error factor” is an abstract expression, it is difficult to decide which objects in the working method should be improved even when the error factor has been identified. Therefore, it is difficult to plan concrete countermeasures by using the guidelines shown above.
2.2 The Approach of this Study
If the improvement object related to the error factor can be identified and the necessary error-proofing solution specified, the problem mentioned in section 2.1 can be solved.
Therefore, this study will propose a tool for solving the problem. The tool is developed using the following steps: (1) correlate the error factor with the improvement objects related to it, and (2) correlate the improvement objects with the error-proofing solution that should be adopted. These steps are described in the sections 3.1 and 3.2. Then, the procedure of analyzing the accidents and planning error proofing countermeasures is shown in the section 3.3.
3. PROPOSING A METHOD FOR PLANNING ERROR-PROOFING COUNTERMEASURES
3.1 Correlate the Error Factor with the Improvement Object
In order to correlate error factors with the corresponding improvement objects, it is necessary to (1) analyze medical accidents, extract the improvement objects, and then arrange the results; and, thereafter, (2) correlate the error factors with the improvement objects.
Medication service involves a series of processes, beginning with a doctor’s prescription of medicines for a patient and ending in the administration of relevant medicines by nurses to the respective patients. Therefore, it is necessary to extract the improvement objects from each working method. This study utilizes the work elements proposed by Kuribara et al. in order to classify error factors depending on the work element and error mode (this study refers to the classified error factor as the “work factor”). This makes it possible to determine the questionable improvement objects. An example is shown below.
By analyzing the accident mentioned above, the work element “determine the administration,” in which a mistake occurred can be handled. Furthermore, the error mode: “skipping” and the error factor “dependence on memory” can be also identified. From the outcome of the analysis, “the prescription” and “immanence memory” can be extracted as improvement objects based on the principles of error proofing. Moreover, the human function “memorize” that should be achieved in the work can also be extracted as an improvement object.
In a similar analysis of 308 medical accidents (during the period 2006.1~2007.3), which were induced by working methods in Hospital A, the main work factors and the improvement objects related to them were extracted. By referring to the figure of Turtle Analysis (Hishinuma, 2004) and the human information processing model (Yoshida, 1998), the extracted improvement objects were systematized using the KJ method. As a result of relating the work factors to the improvement objects, a “map of work factors and improvement objects” was constructed. The map is presented in Table 3.
Table 3 - A map of work factors and improvement objects (extract)
Improvement objectsWork factors / Elements of information / Elements of things / ・・・
Mediums / Contents / Medicine / ・・・ / ・・・
Work elements / Error modes / Error factors / prescription / SS. List / ・・・ / indication of
the information / ・・・ / name / appearance / ・・・ / ・・・
・・・ / ・・・
comprehend
an order of
administration / skipping / scattered
information / ● / ● / ・・・ / ・・・ / ・・・ / …
dependence
on memory / ● / ・・・ / ・・・ / ・・・ / …
・・・ / ・・・
mistake in
perception / various
choices / ● / ● / ・・・ / ● / ・・・ / ・・・ / ・・・
・・・ / …
prepare the
medicine and
the material / mistake in
choice / resemblance
to the name / ● / ・・・ / ・・・ / ● / ・・・ / ・・・
resemblance
to the
appearance / ● / ・・・ / ・・・ / ● / ・・・ / ・・・
・・・ / ・・・ / ・・・
・・・ / ・・・
In this map, the vertical axis shows the work factors and the horizontal axis shows the improvement objects. First, find the work factor of a certain incident on the vertical axis of the map. Then, look for the positions which correspond to the vertical axis. Thus, it is possible to specify the improvement objects related to the work factor easily and ensure that the improvement objects are not overlooked.
3.2 Correlate the Improvement Object with the Error-Proofing Solution
This section describes the correlation of each improvement object extracted in section 3.1 with the appropriate error-proofing solution. In order to accomplish this, the guidelines for planning error-proofing countermeasures against each error factor (Ozaki et al., 2005) and the principles of error proofing (Nakajo et al., 1984) are utilized. Finally, each improvement object is correlated with the error-proofing solution that should be adopted. A part of the results is shown in table 4.
Table 4 - List for improvement object and error-proofing solution
The error-proofingsolution
Improvement objects / Elimination / Completely
Substitution / Partly
Substitution / … / Accommodation / …
do it first / remove / connect / mechanization / sample
and cage / … / … / portable / display information
properly / …
… / …
Prescription / … / ● / …
SS. List / ● / ●
Instructions book / ●
… / ・・・
Layout of information / … / ● / …
Display of information / ●
Name of the medicine / ●
Appearance of the medicine
… / …
Perceiving / ● / ● / ● / … / …
Recognizing / ● / ●
Choosing / ● / ● / ● / ●
… / …
In this list, the vertical axis shows the improvement objects extracted in section 3.1 and the horizontal axis shows the error-proofing solution. First, find the improvement objects that you selected from the map. Then, look for the positions which correspond to the vertical axis. This will indicate the error proofing that should be adopted. Therefore, this list enables one to easily plan error-proofing countermeasures.
3.3 Proposing a Procedure for Planning Countermeasures
Based on the contents in sections 3.1 and 3.2, a procedure of analyzing accidents and planning error-proofing countermeasures is proposed. The details of each step are explained below.
<Step 0> Collecting and classifying medication incidents
[0-1] Collecting medication incidents
Collect information on incidents when there is a difference between the plan and the fact in the work.
[0-2] Distinguishing medication incidents
In addition to the conventional approach, this study utilizes the classification proposed by Nakajo et al. in order to select incidents caused by the working method. The following steps focus only on those incidents that are classified as problems associated with the working method.
<Step 1> Analyzing the incidents to classify the work factor
With regard to every incident classified as a problem of the working method, initially, a work element (25 types) in which a mistake occurs is identified by analyzing an incident. Next, the type of mistake is identified by selecting an error mode (6 types). Finally, the factor of the mistake is identified by selecting an error factor (12 types).
<Step 2> Selecting the improvement object and the error-proofing solution that should be adopted
[2-1] Selecting the improvement object
From the work factor analyzed in step 1, the improvement objects related to it can be selected by referring to the map.
[2-2] Selecting the error-proofing solution that should be adopted
By referring to the list, the error-proofing solution that should be adopted for the improvement object selected in step 2-1 can be identified.
<Step 3> Planning countermeasures
By applying the adopted error-proofing solutions to the improvement objects that were identified in the previous step, countermeasures can be planned.
4. APPLICATION AND VERIFICATION OF THE EFFICACY
4.1 Application of the Method to a Case Example
This section explains the manner in which to utilize the proposed method, taking the following case as an example.
[Case example 2]There are SSA, SSB and SSX, three choices in a SS. List (sliding scale list). Based on the order of doctor, the nurse decides whether to administered medicine to the patient by the result of BS check. This time, A doctor checks the SSX for B patient. But C nurse, who took care of Pt. B, did not prepare medicines, because she misconstrued SSX as SSB.
When an analyst examines an incident due to working methods such as the one mentioned above, the following outcome can be obtained using the proposed method.
[Outcome of the analysis]<Step 1> Analyzing the incidents to classify the work factor
･Work element: “comprehend an order of administration.”
･Error mode: “mistake in perception.”
･Error factor: “various choices.”
<Step 2> Selecting the improvement object and the error proofing that can be adopted
･The improvement objects:
“Instruction book,” “Prescription,” “SS. List,” “Layout of information,” “Display of information,” “Recognizing,” “Choosing.”
･The error-proofing solution:
As an example, “express intentions clearly” will be adopted for the “Instruction book.”
<Step 3> Planning countermeasures
As an example, a countermeasure is planned, such as “attaching the seal on which “SSX” is written to the instruction book.” Other examined examples are shown in table 5.
Table 5 - Examples of error-proofing countermeasures