病院における医薬品関連のインシデントレポート分析の現状と課題に関する全国調査

抄録

Analyzing incident reports is essential in developing countermeasures. This study aimed to identify the current status and issues related to the creation and analysis of incident reports related to medication in hospitals nationwide. An anonymous self-administered questionnaire survey was sent to the medication safety management officers from 2,000 randomly selected hospitals. A total of 409 valid responses were received. Over 90％ of the facilities create and analyze incident reports, regardless of the hospital size or the status of medical safety measure addition. In addition, nearly half of the facilities utilized analytical methods, regardless of the incident’s impact severity on the patient. A trend was observed wherein the frequency of utilizing analytical methods increased with the impact severity. The most frequently used analytical method is the root cause analysis that identifies factors according to the event flow chart, followed by the SHEL/SHELL and P-mSHELL models, which identify factors based on multiple components. By contrast, a tendency for the lesser use of analytical methods was observed in low-impact cases. Many low-impact cases were handled within the department, suggesting a need for support and educational systems. Open-ended responses also showed that the identified challenges differed by hospital size. This study clarified the current status of the utilization of incident report analysis methods, showing that these approaches can effectively be used in hospitals nationwide. The study results provide useful information for investigating the prevention of medication-related incidents based on incident reports.