The comprehensive double loop activities for patient safety management

Fukami, T.; Nagao, Yoshimasa; Uemura, Masakazu

doi:10.1016/j.amsu.2022.103520

Cited by 4 publications

(3 citation statements)

References 3 publications

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“…Medical errors are preventable errors or mistakes that occur in the process of delivering health care [ [1] , [2] , [3] , [4] ]. They can range from minor to more serious errors that may result in significant adverse events for patients.…”

Section: Introductionmentioning

confidence: 99%

“…Common types of medical errors involve medication, diagnose, surgical procedures, communication, and medical records. Medical errors can have a variety of causes, such as poor communication between health care workers and patients, inadequate training, lack of oversight of certain medical processes, and fatigue [ [3] , [4] , [5] ]. To reduce medical errors, health care organizations should focus on improving communication and training, strengthening oversight, and encouraging patient engagement.…”

Section: Introductionmentioning

confidence: 99%

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Patient engagement with psychological safety

Fukami

2023

Dialogues in Health

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Patient engagement with psychological safety

Fukami

2023

Dialogues in Health

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“…The ideal number of incident reports is ve times the number of inpatients (1,2,3,4,5). Because our hospital is a 1,345-bed university hospital, at least 6,725 cases should be reported; however, only 1,210 cases were reported in 2012.…”

Section: Introductionmentioning

confidence: 99%

Measures to foster a safety culture for physicians

Ito

Koike

Hamaguchi

et al. 2022

Preprint

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Introduction: Our hospital began a hospital-wide effort to increase incident reporting around 2012. Since then, the number of reports has increased from 1,210 in 2012 to 16,603 in 2021. However, the number of reports from physicians has not been increasing. Although several measures have been taken to address this situation, the effectiveness of such measures is still unclear. In this study, we compared the numbers of reports from physicians in detail to determine potential effective measures.Methods: We examined the numbers of physicians’ incident reports (at Fujita Health University Hospital) from April 2014 to March 2021. We focused on the reporting rate by physicians out of all incident reports, the number of reports by department, and the number of reports per person by department. We also evaluated the effect of measures and events on improving the increase in incident reports. These include a medical accident investigation system started in 2015, a simplified reporting system established in 2016 for easy reporting, complication reporting standards stipulated in 2017, awareness-raising activities at the training and liaison meetings since 2019, reporting by residents mandated in 2020, and detailed case conferences and feedback for each of the other events. The results were also comparatively examined against the results of safety culture surveys conducted by each department during the same period.Results: Physicians’ incident reporting began to increase in 2015, increasing further with the stipulation of reporting standards in 2017. When it became mandatory for residents to report at least 10 cases per year in 2020, reporting by junior residents increased markedly. Each department, including accident investigation in the clinical department, had a tendency to increase by case. Departments with a high number of reports performed better in the safety culture survey. While the number of patient complaints at hospitals has been increasing nationwide, it has been decreasing at our hospital; this is thought to be one of the effects of these measures.Conclusion: Incident reporting is indispensable in fostering a safety culture among physicians. The survey results indicated that in order to increase the number of incident reports as much as possible, it is important to clearly define the items to be reported. Furthermore, the Safety Office should establish a system for each case and develop a remedial action plan.

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Collaboration and cooperation systems to prevent suicide among children in Japan: effective use of the Observe–Orient–Decide–Act loop

Okada

Suzue

Katayama

et al. 2023

Humanit Soc Sci Commun

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Suicide among school-age children is a serious issue in Japan, exacerbated by the coronavirus disease 2019 pandemic. Collaboration and cooperation between schools—where children spend much of their time—and medical/welfare services are indispensable. However, teachers are overworked, and intensified stress levels have led to high absenteeism. We propose the effective use of the Observe–Orient–Decide–Act (OODA) loop for timely collaboration and cooperation between schools and medical institutions to manage high-risk children as a measure to prevent suicide. We administered questionnaires to 205 teachers who worked with children, nurses, welfare professionals, and school counsellors in schools and related facilities; 171 respondents with valid responses were included. We examined their self-rated health, attitudes towards the OODA loop, levels of depressive symptoms, satisfaction/dissatisfaction with the current status of collaboration and cooperation, and reasons for this. When we compared those satisfied/dissatisfied with the current status of collaboration and cooperation, we found no significant differences in the level of depressive symptoms, but the self-rated health of the latter was poorer. We identified three factors in the attitude survey on the OODA loop—flexible and independent situational assessment, group monitoring and sharing, and self-monitoring—and those who were dissatisfied showed lower scores for all items. We classified the reasons into three categories—details of collaboration and cooperation, methods of collaboration and cooperation, and organisations for collaboration and cooperation—revealing marked differences. The level of satisfaction with the current status of collaboration and cooperation was correlated with the level of mental health. Satisfied participants were more positive about adopting OODA perspectives. Raising awareness of the OODA concept among teaching personnel, creating an organisational structure, establishing systems for appropriate and organic collaboration between schools and medical/welfare institutions, and reviews by external institutions are necessary to effectively use the OODA loop.

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The comprehensive double loop activities for patient safety management

Cited by 4 publications

References 3 publications

Patient engagement with psychological safety

Patient engagement with psychological safety

Measures to foster a safety culture for physicians

Collaboration and cooperation systems to prevent suicide among children in Japan: effective use of the Observe–Orient–Decide–Act loop

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