Table 1 Direct impact on patient care

Direct impact on patient care (n = 39, 45.9%)

Prescription drug (n = 24, 61.5%)

When a member of administrative staff writes a prescription by proxy on behalf of a doctor:

・error in medication name, dose, unit standard, or schedule (15 cases)

・error of wrong transcription of prescribed drugs (9 cases)

The staff member was asked by a doctor to type a drug order and mistyped the amount of the drug. (No. 6)

Prior to the patient’s exam, the staff member was supposed to ask the patient to stop taking the drug, but the patient did not say anything, so the staff member did not specifically ask. On the day of the patient’s exam, the patient was still on the medication. (No. 82)

System administration, information, and documentation. (n = 7, 17.9%)

When a member of the administrative staff uses an electronic (digital) hospital management system for information and documents:

・mistake in telephone call for treatment to another department (3 cases, including one misidentification case)

・mistake in transcribing exam documents (2 cases)

・error in management of hospital ambulance (2 cases)

When I made a phone call regarding the preparation of chemotherapy, I said, “today’s treatment will be done,” but it was wrong. I was supposed to say, “today’s treatment was canceled.” (No. 72)

The staff member forgot to document the items assessed during physical checkup. (No. 7)

Ventilator did not connect to the oxygen valve in the ambulance. Repair technicians had confirmed that this valve connection was broken. (No. 66)

Inquiry (n = 5, 12.8%)

When a member of administrative staff works in hospital intake:

・error of measuring patient’s weight (3 cases)

・mistake in checking patient’s medical device record before exam (2 cases)

The staff member measured patient’s height and weight, and transposed the height and weight on the electronic medical chart. The doctor prescribed the patient’s anti-cancer agent based on this mistyped record. (No. 68)

Other (n = 3, 7.7%)

・Error in acute patient care, administration of vaccine, and misidentification of patient’s meal (1 case each)