Abstract
Hospitals must tackle medication incidents in order to provide high quality medical treatment. Though there are many types of contributing factors, it is effective to identify those which involve the work process and thereby create an opportunity for improvement. Currently, analysis methods such as root-cause analysis（ RCA） and the process-oriented analysis method（ POAM） are utilized. These do not prescribe a procedure in detail for identifying process factors, and as a result, a majority of medical personnel cannot identify them easily or identify potential improvements in the working process.
This paper takes POAM, which focuses on process factors, and identifies reasons for shortcomings in its application. It develops three analysis tools, designated：“medication process model,” “error mode list,” and “identifying factor tree.” It also proposes a method to systematically identify susceptible process factors in the working process. The method is applied to an actual medication incident and the medical staff involved, and improvement of the analysis results is demonstrated.
This method enables medical personnel to identify factors in working processes leading to susceptibility to error, and to plan countermeasures. It can therefore reduce medication incidents.
