Objective: The present study analyzed reports on the incidents and accidents that had occurred in a hospital to examine the status of the misidentification of patients and its characteristics, and discuss effective measures for its early detection and prevention. Subjects and Methods: Of the incident/accident reports on the misidentification of patients submitted during a period of one year, 141 were selected, and relationships among the following factors influencing the misidentification were analyzed: "types of job related to the causes", "types of misidentification", "details of misidentification", "event levels of incidents/accidents", "details of misidentifications", "primary causes of misidentifications", "influences of misidentifications on patients", "persons who identified the misidentifications of patients", and "types of job reported". Results: Whereas patient misidentification due to "errors and the violation of rules while confirming names and other information" was primarily identified by health care professionals, that due to "mix-ups while performing multiple tasks" was often identified by patients and their families, and the difference was significant (p<0.05). From the viewpoint of influences on patients, most patient misidentifications due to "errors and the violation of rules while confirming names and other information" were determined as Level-0 events, for which specific measures had not been implemented, and the majority of patient misidentifications due to "mix-ups while performing multiple tasks" were determined as Level-1 or higher events (p<0.05). In a comparison of nurses and other health care professionals, the frequency of nurses’ misidentifications of patients identified by health care professionals was significantly higher than that identified by patients and their families (p<0.05). Conclusions: It is essential to implement education and establish systems designed to help avoid performing multiple tasks at the same time. The results also suggest that it is necessary to encourage health care professionals to place an emphasis on confirmation involving patients, and continue to promote these activities of the hospital.

View full abstract

This study investigated the status of central venous catheter (CVC) insertion training at university hospitals with the aim to improve the resident training program for the procedure at our hospital. Of the 52 institutions that replied, six reported that, according to the hospital’s management policy, they had data on the total number of CVC insertions, 38 reported that they had developed procedural manuals, and 20 reported having a qualification system for physicians. Regarding residents’ training, 38 institutions had a lecture-based training program of which 34 had a specific program for ultrasound-guided CVC insertion, while 42 institutions had a simulation-based training program of which 39 had a specific program for ultrasound-guided CVC insertion. According to national and international guidelines, ultrasound-guided CVC insertion is recommended as a standard technique. The results of our survey revealed that several institutions were offering training programs based on these guidelines. However, given the importance of these programs including simulation training to ensure the safety of ultrasound-guided CVC insertions, improvement of the educational support system is required.

View full abstract

Authors launched multidisciplinary team, and analyzed medication administration errors according to process flow for reduction of these errors. Medication process was classified into thirteen categories. Dosing errors by patient-self were the largest in number, followed by administration errors to patients from the medication cart and order violations for change or discontinuation of medication by doctors. Main cause of dosing error by patient-self was in assessment for dosing by oneself. Thus, the assessment method was improved, and has been standardized. To reduce the administration errors from a medication cart, reconfirmation by the nurse was conducted. To improve the order violations by doctors, we ensured the awareness of the instruction manual for change or discontinuation of medication. By means of these implementation, tendency of the decrease in medication errors was observed. Process oriented team practice for prevention of medication administration errors by operating the PDCA cycle for standardization was effective.

View full abstract