Japanese

Title	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
Subtitle	一般論文
Authors	江原沙也加1, 柳澤友希1, 木崎速人1, 今井俊吾1, 安室修2, 舟越亮寛2, 堀里子1
Authors (kana)
Organization	1慶應義塾大学薬学部 医薬品情報学講座, 2医療法人鉄蕉会 亀田総合病院 薬剤部
Journal	医療薬学
Volume	51
Number	1
Page	10-19
Year/Month	2025 / 1
Article	原著
Publisher	日本医療薬学会
Abstract	「緒言」世界保健機関 (World Health Organization : WHO) 患者安全カリキュラムガイドではインシデント発生時における, 発生した事実の確定並びに発生源の追求, それに基づく対策立案の必要性を挙げていることからも, インシデントレポートの作成や分析は重要である. インシデントレポートから発生状況を正確に捉え, インシデント発生源を追求するために, 当事者は, 個人に関連する要因情報だけでなく, 作業や環境にかかわるシステムに関する要因情報やコミュニケーション, マネジメントにかかわる要因情報を含めて報告することが必要である. さらに, インシデントレポートの分析では, 効果的な対策立案を目指して, これらの要因を網羅的に発生した事実情報として捉え, 分析することが重要である.
Practice	薬学
Keywords	incident report, patient safety, questionnaire survey, medical institution

English

Title	Nationwide Survey on the Current Status and Issues in Analyzing Drug-related Incident Reports in Hospitals
Subtitle	Regular Articles
Authors	Sayaka Ebara1, Yuki Yanagisawa1, Hayato Kizaki1, Shungo Imai1, Osamu Yasumuro2, Ryohkan Funakoshi2, Satoko Hori1
Authors (kana)
Organization	1Division of Drug Informatics, Keio University Faculty of Pharmacy, 2Department of Pharmacy, Kameda General Hospital
Journal	Japanese Journal of Pharmaceutical Health Care and Sciences
Volume	51
Number	1
Page	10-19
Year/Month	2025 / 1
Article	Original article
Publisher	Japanese Society of Pharmaceutical Health Care and Sciences
Abstract	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.
Practice	Pharmaceutical sciences
Keywords	incident report, patient safety, questionnaire survey, medical institution

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