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Adverse events associated with failed airway management may have catastrophic consequences, and despite many advances in knowledge, guidelines and equipment, airway incidents and patient harm continue to occur. Patient safety incident reporting systems have been established to facilitate a reduction in incidents. However, it has been found that corrective actions are inadequate and successful safety improvements scarce. The aim of this scoping review was to assess whether the same is true for airway incidents by exploring academic literature that describes system changes in airway management in high-income countries over the last 30 years, based on findings and recommendations from incident reports and closed claims studies. This review followed the most recent guidance from the Joanna Briggs Institute (JBI). PubMed, Ovid MEDLINE and Embase, the JBI database, SCOPUS, the Cochrane Library and websites for anaesthetic societies were searched for eligible articles. Included articles were analysed and data synthesised to address the review's aim. The initial search yielded 28,492 results, of which 111 articles proceeded to the analysis phase. These included 23 full-text articles, 78 conference abstracts and 10 national guidelines addressing a range of airway initiatives across anaesthesia, intensive care and emergency medicine. While findings and recommendations from airway incident analyses are commonly published, there is a gap in the literature regarding the resulting system changes to reduce the number and severity of adverse airway events. Airway safety management mainly focuses on Safety-I events and thereby does not consider Safety-II principles, potentially missing out on all the information available from situations where airway management went well.

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Oesophageal intubations are more common than may be realised and can potentially cause significant patient harm even if promptly identified and corrected. Reports of morbidity due to unrecognised oesophageal intubation continue to present in coroner and media reports. Therefore, it would be helpful to identify mechanisms to prevent these events and implement strategies to avoid and identify incorrect endotracheal tube placement. This analysis of oesophageal intubations reported to webAIRS aims to provide an in-depth analysis of all events in which oesophageal intubation occurred. WebAIRS is a web-based, bi-national incident reporting system collecting voluntarily reported anaesthetic events across Australia and New Zealand, with more than 10,500 incidents registered. A structured search through the webAIRS database identified 109 reports of oesophageal intubation reported between July 2009 and September 2022. A common cause of oesophageal intubation was the misidentification of the larynx due to a poor laryngeal view. Desaturation directly attributed to the misplaced endotracheal tube occurred in 43% of all reports. The authors precisely defined early recognised oesophageal intubation and delayed or unrecognised oesophageal intubation. Most reports (74%) described early recognition of the misplaced intubation, of which 27% led to directly contributed to hypoxia. Cardiovascular collapse as a direct consequence of the late recognition of oesophageal intubation was described in five (18%) of these events. There was inconsistency in end-tidal carbon dioxide monitoring and interpretation of the resulting waveform. Findings show that oesophageal intubation continues to be an issue in anaesthesia. Incidents described confusion in diagnosis, human factors issues and cognitive bias. Clear diagnostic guidance and treatment strategies are required to be developed, tested and implemented.

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Incident reporting and learning systems provide an opportunity to identify systemic vulnerabilities that contribute to incidents and potentially degrade quality. The narrative of an incident is intended to provide a clear, easy to understand description of an incident. Unclear, incomplete or poorly organized narratives compromise the ability to learn from them. This report provides guidance for drafting effective narratives, with particular attention to the use of narratives in incident reporting and learning systems (IRLS). Examples are given that compare effective and less than effective narratives. This report is mostly directed to organizations that maintain IRLS, but also may be helpful for individuals who desire to write a useful narrative for entry into such a system. Recommendations include the following: (1) Systems should allow a one- or two-sentence, free-text synopsis of an incident without guessing at causes; (2) Information included should form a sequence of events with chronology; and (3) Reporting and learning systems should consider using the headings suggested to guide the reporter through the narrative: (a) incident occurrences and actions by role; (b) prior circumstances and actions; (c) method by which the incident was identified; (d) equipment related details if relevant; (e) recovery actions by role; (f) relevant time span between responses; (g) and how individuals affected during or immediately after incident. When possible and appropriate, supplementary information including relevant data elements should be included using numerical scales or drop-down choices outside of the narrative. Information that should not be included in the narrative includes: (a) patient health information (PHI); (b) conjecture or blame; (c) jargon abbreviations or details without specifying their significance; (d) causal analysis.

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AIM: To describe the contributing factors and types of reported medication incidents in home care related to the flow of information in different phases of the medication process, as reported by multi-professional healthcare groups. DESIGN: This descriptive, qualitative study used retrospective data. METHODS: An incident-reporting database was used to collect 14,289 incident reports from 2017 to 2019 in a city in Finland. We used this data to select medication incidents (n = 1027) related to the flow of information in home care and between home care and hospitals. Data were divided into five groups based on the medication phase: (1) prescribing, (2) dispensing, (3) administration, (4) documentation and (5) self-administration. In addition, the types of medication-related incidents were described. The data were examined using abductive content analysis. The EQUATOR SRQR checklist was used in this report. RESULTS: Four main categories were identified from the data: (1) issues related to information management, (2) cooperation issues between different actors, (3) work environment and lack of resources and (4) factors related to healthcare workers. Cooperation issues contributed to medication-related incidents during each phase. Incomplete communication was a contributing factor to medication incidents. This occurred between home care, remote care, hospital, the client and the client's relatives. Specifically, a lack of information-sharing occurred in repatriation situations, where care transitioned between different healthcare professionals. CONCLUSION: Healthcare professionals, organisations, clients and their relatives should focus on the efficient and safe acquisition of medications. Specifically, the use of electronic communication systems, together with oral reports and checklists for discharge situations, and timely cooperation with pharmacists should be developed to manage information flows. RELEVANCE TO CLINICAL PRACTICE: These findings demonstrate that healthcare professionals require uniform models and strategies to accurately and safely prescribe, dispense and administer medications in home care settings. No patient or public contributions.

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BACKGROUND: Medication errors in the intensive care setting continue to occur at significant rates and are often associated with adverse events and potentially life-threatening repercussions. AIM/OBJECTIVE: The aim of this study was to (i) determine the frequency and severity of medication errors reported in the incident management reporting system; (ii) examine the antecedent events, their nature, the circumstances, risk factors, and contributing factors leading to medication errors; and (iii) identify strategies to improve medication safety in the intensive care unit (ICU). METHOD: A retrospective, exploratory, descriptive design was selected. Retrospective data were collected from the incident report management system and electronic medical records over a 13-month period from a major metropolitan teaching hospital ICU. RESULTS: A total of 162 medication errors were reported during a 13-month period, of which, 150 were eligible for inclusion. Most medication errors occurred during the administration (89.4%) and dispensing phases (23.3%). The highest reported errors included incorrect doses (25.3%), incorrect medications (12.7%), omissions (10.7%), and documentation errors (9.3%). Narcotic analgesics (20%), anaesthetics (13.3%), and immunomodifiers (10.7%) were the most frequently reported medication classes associated with medication errors. Prevention strategies were found to be focussed on active errors (67.7%) as opposed to latent errors (32.3%) and included various and infrequent levels of education and follow-up. Active antecedent events included action-based errors (39%) and rule-based errors (29.5%), whereas latent antecedent events were most associated with a breakdown in system safety (39.3%) and education (25%). CONCLUSION: This study presents an epidemiological view and understanding of medication errors in an Australian ICU. This study highlighted the preventable nature of most medication errors in this study. Improving administration-checking procedures would prevent the occurrence of many medication errors. Approaches aimed at both individual- and organisational-level improvements are recommended to address administration errors and inconsistent medication-checking procedures. Areas for further research include determining the most effective system developments for improving administration-checking procedures and verifying the risk and prevalence of immunomodifier administration errors in the ICU as this is an area not reported previously in the literature. In addition, the impact of single- versus two-person checking procedures on medication errors in the ICU should be prioritised to address current evidence gaps.

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BACKGROUND: Monitoring workplace violence (WPV) against health care workers (HCWs) through incident reporting is crucial to drive prevention, but the actual implementation is spotty and experiences underreporting. OBJECTIVE: This study aims to introduce a systematic WPV surveillance in 2 public referral hospitals in Italy and assess underreporting, WPV annual rates, and attributes "before" (2016-2020) and "after" its implementation (November 2021 to 2022). METHODS: During 2016-2020, incident reporting was based on procedures and data collection forms that were neither standardized between hospitals nor specific for aggressions. We planned and implemented a standardized WPV surveillance based on (1) an incident report form for immediate and systematic event notification, adopting international standards for violence definitions; (2) second-level root cause analysis with a dedicated psychologist, assessing violence determinants and impacts and offering psychological counseling; (3) a web-based platform for centralized data collection; and (4) periodic training for workforce coordinators and newly hired workers. We used data from incident reports to estimate underreporting, defined as an observed-to-expected (from literature and the "before" period) WPV ratio less than 1, and the 12-month WPV rates (per 100 HCWs) in the "before" and "after" periods. During the latter period, we separately estimated WPV rates for first and recurrent events. RESULTS: In the "before" period, the yearly observed-to-expected ratios were consistently below 1 and as low as 0.27, suggesting substantial violence underreporting of up to 73%. WPV annual rates declined in 1 hospital (from 1.92 in 2016 to 0.57 in 2020) and rose in the other (from 0.52 to 1.0), with the divergence being attributable to trends in underreporting. Available data were poorly informative to identify at-risk HCW subgroups. In the "after" period, the observed-to-expected ratio rose to 1.14 compared to literature and 1.91 compared to the "before" period, consistently in both hospitals. The 12-month WPV rate was 2.08 (95% CI 1.79-2.42; 1.52 and 2.35 in the 2 hospitals); one-fifth (0.41/2.08, 19.7%) was due to recurrences. Among HCWs, the youngest group (3.79; P<.001), nurses (3.19; P<.001), and male HCWs (2.62; P=.008) reported the highest rates. Emergency departments and psychiatric wards were the 2 areas at increased risk. Physical assaults were more likely in male than female HWCs (45/67, 67.2% vs 62/130, 47.7%; P=.01), but the latter experienced more mental health consequences (46/130, 35.4% vs 13/67, 19.4%; P=.02). Overall, 40.8% (53/130) of female HWCs recognized sociocultural (eg, linguistic or cultural) barriers as contributing factors for the aggression, and 30.8% (40/130) of WPV against female HCWs involved visitors as perpetrators. CONCLUSIONS: A systematic WPV surveillance reduced underreporting. The identification of high-risk workers and characterization of violence patterns and attributes can better inform priorities and contents of preventive policies. Our evaluation provides useful information for the large-scale implementation of standardized WPV-monitoring programs.

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Peripheral venous catheterization (PVC) is the most commonly used invasive technique, and its importance to patient safety is increasing. And phlebitis is a common complication which can lead to increased costs and extended hospital stays. This study attempted to characterize the current status of phlebitis based on incident reports in the Korea Patient Safety Reporting & Learning System. This retrospective descriptive study analysed 259 phlebitis cases reported in that system from 1 July 2017 to 31 December 2019. The analysis results were summarized using numbers and percentages or means with standard deviations. Among the reported phlebitis cases, antibiotics and high-osmolarity fluids comprised 48.2% of the intravenous inflammatory drugs used. All reported cases presented blood-flow infections. Insufficient observation or management was the most common cause of phlebitis. It was found that interventions for phlebitis were inconsistent with those recommended in evidence-based guidelines. Recommendations for nurses to alleviate complications in PVC must be promoted and educated. It is necessary to provide feedback from the incident reports analysis.

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Introduction: Improving medication safety during transition of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy. Aim: To characterise the nature and contributory factors of medication-related incidents during transition of care from secondary to primary care. Method: A retrospective analysis of medication incidents reported to the National Reporting and Learning System (NRLS) in England and Wales between 2015 and 2019. Descriptive analysis identified the frequency and nature of incidents and content analysis of free text data, coded using the Patient Safety Research Group (PISA) classification, examined the contributory factors and outcome of incidents. Results: A total of 1121 medication-related incident reports underwent analysis. Most incidents involved patients over 65 years old (55%, n = 626/1121). More than one in 10 (12.6%, n = 142/1121) incidents were associated with patient harm. The drug monitoring (17%) and administration stages (15%) were associated with a higher proportion of harmful incidents than any other drug use stages. Common medication classes associated with incidents were the cardiovascular (n = 734) and central nervous (n = 273) systems. Among 408 incidents reporting 467 contributory factors, the most common contributory factors were organisation factors (82%, n = 383/467) (mostly related to continuity of care which is the delivery of a seamless service through integration, co-ordination, and the sharing of information between different providers), followed by staff factors (16%, n = 75/467). Conclusion: Medication incidents after hospital discharge are associated with patient harm. Several targets were identified for future research that could support the development of remedial interventions, including commonly observed medication classes, older adults, increase patient engagement, and improve shared care agreement for medication monitoring post hospital discharge. Plain language summary: Study using reports about unsafe or substandard care mainly written by healthcare professionals to better understand the type and causes of medication safety problems following hospital discharge Why was the study done? The safe use of medicines after hospital discharge has been highlighted by the World Health Organization as an important target for improvement in patient care. Yet, the type of medication problems which occur, and their causes are poorly understood across England and Wales, which may hamper our efforts to create ways to improve care as they may not be based on what we know causes the problem in the first place.What did the researchers do? The research team studied medication safety incident reports collected across England and Wales over a 5-year period to better understand what kind of medication safety problems occur after hospital discharge and why they happen, so we can find ways to prevent them from happening in future.What did the researchers find? The total number of incident reports studied was 1121, and the majority (n = 626) involved older people. More than one in ten of these incidents caused harm to patients. The most common medications involved in the medication safety incidents were for cardiovascular diseases such as high blood pressure, conditions such as mental illness, pain and neurological conditions (e.g., epilepsy) and other illnesses such as diabetes. The most common causes of these incidents were because of the organisation rules, such as information sharing, followed by staff issues, such as not following protocols, individual mistakes and not having the right skills for the task.What do the findings mean? This study has identified some important targets that can be a focus of future efforts to improve the safe use of medicines after hospital discharge. These include concentrating attention on medication for the cardiovascular and central nervous systems (e.g., via incorporating them in prescribing safety indicators and pharmaceutical prioritisation tools), staff skill mix (e.g., embedding clinical pharmacist roles at key parts of the care pathway where greatest risk is suspected), and implementation of electronic interventions to improve timely communication of medication and other information between healthcare providers.

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BACKGROUND: Patient safety is associated with patient outcomes. However, there is insufficient evidence of patient safety in the dental field. This study aimed to compare incidents reported by dentists and physicians, compare the type of errors made by them, and identify how dentists prevent dental errors. METHODS: A mixed-methods study was conducted using open data from the Japan Council for Quality Health Care database. A total of 6071 incident reports submitted for the period 2016-2020 were analyzed; the number of dentists' incident reports was 144, and the number of physicians' incident reports was 5927. RESULTS: The percentage of dental intern reporters was higher than that of medical intern reporters (dentists: n = 12, 8.3%; physicians: n = 180, 3.0%; p = 0.002). The percentage of reports by dentists was greater than that by physicians: wrong part of body treated (dentists: n = 26, 18.1%; physicians: n = 120, 2.0%; p < 0.001), leaving foreign matter in the body (dentists: n = 15, 10.4%; physicians: n = 182, 3.1%; p < 0.001), and accidental ingestion (dentists: n = 8, 5.6%; physicians: n = 8, 0.1%; p < 0.001), and aspiration of foreign body (dentists: n = 5, 3.4%; physicians: n = 33, 0.6%; p = 0.002). The percentage of each type of prevention method utilized was as follows: software 27.8% (n = 292), hardware (e.g., developing a new system) 2.1% (n = 22), environment (e.g., coordinating the activities of staff) 4.2% (n = 44), liveware (e.g., reviewing procedure, double checking, evaluating judgement calls made) 51.6% (n = 542), and liveware-liveware (e.g., developing adequate treatment plans, conducting appropriate postoperative evaluations, selecting appropriate equipment and adequately trained medical staff) 14.3% (n = 150). CONCLUSION: Hardware and software and environment components accounted for a small percentage of the errors made, while the components of liveware and liveware-liveware errors were larger. Human error cannot be prevented by individual efforts alone; thus, a systematic and holistic approach needs to be developed by the medical community.

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BACKGROUND: Medication errors regardless of the degree of patient harm can have a negative emotional impact on the healthcare staff involved. The potential for self-victimization of healthcare staff following medication errors can add to the moral distress of healthcare staff. The stigma associated with errors and their disclosure often haunts healthcare professionals, leading them to question their own professional competence. This paper investigates the negative emotions expressed by healthcare staff in their reported medication administration error incidents along with the immediate responses they received from their seniors and colleagues after the incident. METHOD: This is a retrospective study using a qualitative descriptive design and text mining. This study includes free-text descriptions of medication administration error incidents (n = 72,390) reported to National Reporting & Learning System in 2016 from England and Wales. Text-mining by SAS text miner and content analysis was used to analyse the data. RESULTS: Analysis of data led to the extraction of 93 initial codes and two categories i.e., 1) negative emotions expressed by healthcare staff which included 4 sub-categories of feelings: (i) fear; (ii) disturbed; (iii) sadness; (iv) guilt and 2) Immediate response from seniors and colleagues which included 2 sub-categories: (i) Reassurance and support and (ii) Guidance on what to do after an error. CONCLUSION: Negative emotions expressed by healthcare staff when reporting medication errors could be a catalyst for learning and system change. However, negative emotions when internalized as fear, guilt, or self-blame, could have a negative impact on the mental health of individuals concerned, reporting culture, and opportunities for learning from the error. Findings from this study, hence, call for future research to investigate the impact of negative emotions on healthcare staff well-being and identify ways to mitigate these in practice.

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Purpose: To describe the long-term quantitative change in the number of submissions of patient safety reports after the introduction of a patient safety reporting system, focusing on incident severity and type. Patients and Methods: This study was performed at a tertiary care hospital in Japan. Patient safety reports from 2006 to 2020 were retrospectively reviewed. Incident severity was classified from level 0 (near miss) to level 5 (fatality). The incident types included those related to medication, patient care, drains and catheters, procedures and interventions, examinations, medical devices, and blood transfusions. The study period was divided into 1. 2004-2007; 2. 2008-2014; and 3. 2015-2020 based on the implementation of hospital patient safety strategies. The number of reports per hospital worker was compared among the study periods and the incident levels and types. Results: We analyzed 96,332 reports extracted from the patient safety reporting system of the hospital. The total number of reports per hospital worker has increased over time. The numbers of levels 0 and 1 incidents increased throughout the study period. In addition, levels 3a and 3b incidents increased between periods 2 and 3. All incident types, except for procedure and intervention-related incidents, increased between periods 1 and 2 and between periods 1 and 3. The number of procedure and intervention-related incidents increased between periods 2 and 3, although it did not between periods 1 and 2. Conclusion: We found increases in the number of patient safety reports according to the incident severity and type. This suggests two contextual changes occurring during the cultural maturity process, which reflected the development of organizational patient safety culture in our institution. The first was the establishment of a reporting attitude in the institution. The second was to overcome barriers to patient safety.

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Patient outcome is one of the key information categories in incident reporting. Being able to extract meaningful patient fall outcomes would allow better analysis of the consequences and possible mitigating actions for in-hospital fall incidents. This study aims to automate the extraction of patient outcomes from narrative fall incident reports by decomposing this into three classification subtasks: injured or not, injury types, and the number of injuries. Implementing an existing incident report classification (IRC) framework, the experimental results demonstrated that oversampling and structured features were effective to achieve better overall performances across all three subtasks. The study further validated the application of an IRC framework to deal with imbalanced classification problems found in fall patient outcome classification and advanced the science of automatic patient outcomes extraction.

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We practice patient safety as a model that links patient safety and quality improvement in healthcare. The most important activity is the incident report. The loop on the left is during usual situation activity related to quality improvement in healthcare. The loop on the right is during critical situations activity related to patient safety. What is important in these activities is the initial response to the critical situation, which is the first corner of the right loop. We practice emphasizing the initial response to the critical situation, creating the pattern, and taking measures without omissions. Although many patient safety measures have been taken, it has become clear that there is a shortage of doctors who can practice them. We have practiced that pattern and supported advanced healthcare. We want you to explain the pattern and use it in practice.

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The purpose of this study was to describe incident reporters' views identified by artificial intelligence concerning the prevention of medication incidents that were assessed, causing serious or moderate harm to patients. The information identified the most important risk management areas in these medication incidents. This was a retrospective record review using medication-related incident reports from one university hospital in Finland between January 2017 and December 2019 (n = 3496). Of these, incidents that caused serious or moderate harm to patients (n = 137) were analysed using artificial intelligence. Artificial intelligence classified reporters' views on preventing incidents under the following main categories: (1) treatment, (2) working, (3) practices, and (4) setting and multiple sub-categories. The following risk management areas were identified: (1) verification, documentation and up-to-date drug doses, drug lists and other medication information, (2) carefulness and accuracy in managing medications, (3) ensuring the flow of information and communication regarding medication information and safeguarding continuity of patient care, (4) availability, update and compliance with instructions and guidelines, (5) multi-professional cooperation, and (6) adequate human resources, competence and suitable workload. Artificial intelligence was found to be useful and effective to classifying text-based data, such as the free text of incident reports.

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AIMS: To describe the characteristics of medication administration (MA) incidents reported to have occurred in patients' own homes (reporters' profession, incident types, contributing factors, patient consequence, and most common medications involved) and to identify the connection terms related to the most common contributing factors based on free text descriptions. DESIGN: A retrospective study using descriptive statistical analysis and text mining. METHODS: Medication administration incidents (N = 19,725) reported to have occurred in patients' homes between 2013-2018 in one district in Finland were analysed, describing the data by the reporters' occupation, incident type, contributing factors, and patient consequence. SAS® Text Miner was used to analyse free text descriptions of the MA incidents to understand contributing factors, using concept linking. RESULTS: Most MA incidents were reported by practical (lower level) nurses (77.8%, N = 15,349). The most common category of harm was 'mild harm' (40.1%, N = 7,915) and the most common error type was omissions of drug doses (47.4%, N = 9,343). The medications most commonly described were Marevan [warfarin] (N = 2,668), insulin (N = 811), Furesis [furosemide] (N = 590), antibiotic (N = 446), and Panadol [paracetamol] (N = 416). The contributing factors most commonly reported were 'communication and flow of information' (25.5%, N = 5,038), 'patient and relatives' (22.6%, N = 4,451), 'practices' (9.9%, N = 1,959), 'education and training' (4.8%, N = 949), and 'work environment and resources' (3.0%, N = 598). CONCLUSION: There is need for effective communication and clear responsibilities between home care patients and their relatives and health providers, about MA and its challenges in home environments. Knowledge and skills relating to safe MA are also essential. IMPACT: These findings about MA incidents that have occurred in patients' homes and have been reported by home care professionals demonstrate the need for medication safety improvement in home care.

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OBJECTIVE: To compare the frequency and type of inpatient Parkinson's medication errors reported through an incident report system versus those identified through retrospective case note review in a tertiary teaching hospital. METHODS: A search of inpatient medication-related incident reports identified those pertaining to Parkinson's medication. A discharge diagnoses search identified admissions for patients with Parkinson's disease over the same time period. A retrospective case note and incident report review were performed to describe and quantify medication-related events. KEY FINDINGS: Substantially, more medication-related problems were identified via case note review (n = 805) versus incident reporting system (n = 19). A significantly different pattern of error types was identified utilising case note review versus incident reporting, with case note review more likely to identify delayed dosing, and incident reports more likely to identify wrong dose or formulation administered errors. CONCLUSIONS: Retrospective incident report and case note review can be used to characterise medication administration errors encountered in an inpatient setting. Incident report review alone is insufficient in estimating error rates, and dual data collection methods should be used.

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PURPOSE: (a) To describe trigger terms that can be used to identify reports of inadequate staffing contributing to medication administration errors, (b) to identify such reports, (c) to compare the degree of harm within incidents with and without those triggers, and (d) to examine the association between the most commonly reported inadequate staffing trigger terms and the incidence of omission errors and "no harm" terms. DESIGN AND SETTING: This was a retrospective study using descriptive statistical analysis, text mining, and manual analysis of free text descriptions of medication administration-related incident reports (N = 72,390) reported to the National Reporting and Learning System for England and Wales in 2016. METHODS: Analysis included identifying terms indicating inadequate staffing (manual analysis), followed by text parsing, filtering, and concept linking (SAS Text Miner tool). IBM SPSS was used to describe the data, compare degree of harm for incidents with and without triggers, and to compare incidence of "omission errors" and "no harm" among the inadequate staffing trigger terms. FINDINGS: The most effective trigger terms for identifying inadequate staffing were "short staffing" (n = 81), "workload" (n = 80), and "extremely busy" (n = 51). There was significant variation in omission errors across inadequate staffing trigger terms (Fisher's exact test = 44.11, p < .001), with those related to "workload" most likely to accompany a report of an omission, followed by terms that mention "staffing" and being "busy." Prevalence of "no harm" did not vary statistically between the trigger terms (Fisher's exact test = 11.45, p = 0.49), but the triggers "workload," "staffing level," "busy night," and "busy unit" identified incidents with lower levels of "no harm" than for incidents overall. CONCLUSIONS: Inadequate staffing levels, workload, and working in haste may increase the risk for omissions and other types of error, as well as for patient harm. CLINICAL RELEVANCE: This work lays the groundwork for creating automated text-analytical systems that could analyze incident reports in real time and flag or monitor staffing levels and related medication administration errors.

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We investigated the causes and trends of incidents related to radiography. From April 2014 to March 2016, 384 incident reports related to radiography were posted. We analyzed based on the nature of the incidents and the experience period of radiological technologist (RT). The types of incidents were 'Incorrect examination order by medical doctor' (50.0%), 'X-ray retake' (24%), 'Incorrect examination procedure' (9.9%), 'Fall or injury of the patient under examination' (3.6%), 'selection error of X-ray detector' (3.1%), 'patient mismatch' (1.8%), 'overdose' (1.3%), and 'others' (a malfunctioning device, trouble of systems and the other) (6.5%). There was no relationship between the number of incidents per person and the experience period as RT; (7.8/person for <3 years of experience, 9.7/person for 3-10 years, 6.4/person for 11-25 years of experience, 7.4/person for <25 years of experience). The experience period as RT are related to some types of incident reduction. 'Fall or injury of the patient under examination' and 'overdose' were more frequently reported by RTs of shorter experience (<3 years and 3-10 years of experience) than RTs of longer experience (11-25 years and <25 of experience). On the other hand, 'patient mismatch' and 'selection error of X-ray detector' were more frequently reported by RTs of long experience than RTs of short experience.

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PURPOSE: The purpose of this paper is to analyze the characteristics of incidents related to routes and drains that occur in the radiological examination room for the prevention of these incidents. METHODS: We conducted a questionnaire survey on incident cases that occurred in the radiological examination room. There were 373 responses, of which 76 responses were related to routes and drains. The question contents were the number of hospital beds, radiology department of occurrence, time of occurrence, patient's situation, method of visiting, years of experience of the radiological technologists, and countermeasures, and so on. Based on these answers to these questions, we analyzed which factors were involved in the occurrence of the incidents. RESULTS: Incidents related to routes and drains often occur when moving examination table or transferring the patients to the examination table using the slider. On the other hand, the years of experience of the radiological technologists hardly participated in the factor of these incidents. From these answers to questions, 75% of incidents might predictable, and these incidents could be prevented by improvement of human factors accounted for the majority rather than that of physical factors. CONCLUSION: The number of incidents related to routes and drains may reduce by that all staff involved in the radiological examination recognizing the characteristic of these incidents.

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