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Table 3 Illustrative examples: discussion of possible causes and the use of systems approach

From: How do healthcare practitioners use incident data to improve patient safety in Japan? A qualitative study

 

Acute Care

Mental Health

Exploration of possible causes

Vascular injury due to catheterization: brief exchange of viewpoints regarding complications of catheter manipulation

Missed information around food allergy: lack of communication between the nutrition department and the ward

Consideration of systems problems

Cerebral infarction after Coronary Angiography (CAG): unclear lines of responsibility in the process of obtaining informed consent and describing the risk of complication deriving from CAG

Patient’s unplanned entry to electroconvulsive therapy: miscommunication between different units

Critiquing of hypothesized causes

Very little discussion, with some exceptions

Not observed

Seeking further information about the incident

Not much discussion, apart from questions as to subsequent actions made by a doctor involved in the case, and the relevant electronic medical records

Follow-up information requested for cases where the information about how incidents occurred was not complete