In 2002, the Dental Hospital of Tokyo Medical and Dental University set up a working group for risk management. This working group analyzed 225 incident and accident reports submitted to the hospital in 2001 and 2002. Each report was analyzed with regard to“type, ”“place, ”“reporter, ”“severity, ”and“cause”in order to diagnose hospital safety and prevent future incidents and accidents.
The cause of incidents and accidents was analyzed using the SHEL model, where S stands for Software, H for Hardware, E for Environment, and L for Liveware. The severity of the consequence was classified into 6 levels, where level 0=“error not applied, ”level 1=“not affected, ”level 2=“watch and see or additional test, ”level 3=“treatment, ”level 4=“aftereffect, ”and level 5=“death.”The incidents and accidents judged to have potentially high risk were given a score of “+ H, ”irrespective of the level.
The results of the analyses revealed that most of the incidents and accidents happened in“wards, ”“operation rooms, ”and“oral surgery clinics.”This is probably because the incident and accident reporting system is well established by nurses working in these clinics. Additional analysis revealed that most of the reports were written and submitted by nurses. The frequencies of“treatment procedure, ”“misuse of dental instruments, ”“mis-prescription, ”“falling down” and“needlestick”related incidents and accidents were the highest and were caused mainly by L and S. There were only 3 accidents above level 4, however, less severe cases were given a score of +H due to the high potential risk involved.
