Improvement framework for safety rule using incident reporting and worker's practical heuristics (Empirical consideration in patient safety management)

In patient safety management fields, there are quite large number of incidents in which failures involved could easily be prevented by “already-known measures”. This paper describes the frame-work of learning “good practice” using incidents reports and worker's heuristics in order to take measures for the causes of the incidents. The proposed concept is applied to a safety management activity in Kyushu University hospital, which is one of educational central hospitals in Japan. A distinct number of reports collected from May 2005 to March 2006 is 1 635, which contains a cause of malpractice of checking is 65.9%, a cause of malpractice of process is 26.2% and other is 7.9%. By comparing local practices in sections to prevent failures in drug confirmation, the authors has determined effective practices, which we calls “acceptable safety rule” that achieves safety, efficiency in practice and the acceptance by workers or cooperative patients. Consequently, our proposed framework is validly effective to improve the contents of safety rule introducing a worker's experience, in order to create “acceptable safety rule” which is safe and does not disturb an efficiency of worker's action. This framework can be applicable not only in a patient safety, but also in an engineering system safety.