A study on the method of designing



A STUDY ON THE METHOD OF DESIGNING KIKEN YOCHI TRAINING SHEETS (HAZARD PREDICTION TRAINING SHEETS) IN MEDICAL SERVICE

Chisato KAJIHARA1 Masahiko MUNECHIKA2 Masaaki KANEKO3

ABSTRACT

Safety procedures are carried out in hospitals to prevent medical incidents and to provide high-quality medical services. Many hospitals have introduced Kiken Yochi Training (KYT) as one of these safety procedures; KYT involves training to improve the ability to identify hazards by discussing the hidden hazards depicted in the KYT sheet, which demonstrates the workplace and working conditions. However, there is no established method to make KYT sheets. This study proposes a method of designing KYT sheets for use in the prevention medical incidents.

In order to effectively implement KYT for preventing medical incidents, the incidents to be represented on the KYT sheet should be determined according to the number of occurrences and the incident factors should be properly represented on the KYT sheet. Additionally, the answer to the KYT sheet is necessary for evaluating the ability to identify hazards. Therefore, 30 medication incidents in hospital A were analyzed as follows: counting the number of occurrences, arranging factors by using the P-mSHELL model, determining how to represent factors on the KYT sheet, and analyzing unsafe behavior and the effects of incidents for preparing a hazard-story. In addition, the results of analysis were arranged in an incident list to reflect the results on the KYT sheet.

This study proposed the following design method by utilizing the incident list; (1) deciding the incidents to be represent on the KYT sheet, (2) preparing hazard-story for the answer to the KYT sheet, (3) setting the work conditions for the KYT sheet and taking photographs, and (4) establishing condition-setting. By using the proposed design method, the KYT sheets outlining the occurrence of medical incidents can be prepared. KYT was executed using KYT sheets made according to the proposed method. The result of this study revealed an improved ability to identify hazards.

Key Words: medical safety, medication incidents, KYT (Hazard Prediction Training)

INTRODUCTION

Quality and safety in the medical service have recently come under increasing public scrutiny. Therefore, it is necessary for hospitals to provide a high-quality healthcare service. Furthermore, as a consequence of a revision of the payment system for medical service in Japan, many new nurses are now being employed in hospitals. However, the employment of many new nurses who do not have the requisite nursing knowledge and skills has let to an increase in the number of medical incidents. Medical incidents also occur as a result of the careless actions of intermediate and senior nurses. Therefore, it is essential that safe procedures that lead to the prevention of medical incidents are conducted in hospitals.

Many hospitals have introduced Kiken Yochi Training (KYT), or Hazard Prediction Training. KYT is a training method designed to improve the ability to identify hazards by discussing the hidden hazards depicted in KYT sheets that show the workplace and work conditions. However, because there is no standard procedure for producing KYT sheets, creating such sheets is dependent on the nurses themselves. Therefore, effective KYT for the prevention of medical incidents is typically not executed. In order to conduct effective KYT, it is necessary to produce KYT sheets in order to educate on various incident factors.

The purpose of this study was to propose a design method for KYT sheets to be use for educating on the prevention of medical incidents.

INVESTIGATING THE CURRENT SITUATION

The KYT Method

KYT sheets are used to show the workplace and work conditions, to promote discussion on the hazardous factors in the workplace and in work conditions (unsafe conditions and unsafe behavior that may lead to medical incidents), and to stimulate discussion on the phenomena (type of incidents) that may arise from such factors. The sheets also enable information on hazards to be shared among members of the workforce. Finally, they provide a focus for meetings convened to find solutions to hazards. Thus, KYT is considered as a training tool designed to improve the ability to notice hazards and to solve problems. The following points summarize the KYT procedure.

1] Understanding the actual situation: Discuss the hazards depicted in the KYT sheet. When members discuss the hazards, they relate a “hazard-story”; a “hazard-story” describes the relationship between hazardous factors, unsafe behavior that may arise from such factors, and the incident phenomena that may arise from unsafe behavior.

2] Determining the hazard points: Select the hazard that members should solve from the hazards found in step [1].

3] Establishing measures: Establish measures to solve the hazards selected in step [2] - as many as possible.

4] Setting goals: Select the measures that members have to adopt from the measures that were established in step [3].

The Current Problem with KYT

It is necessary to understand the current problem with KYT in order to propose a design method for KYT sheets. Therefore, literatures on the KYT conducted in the industrial world and in medical service were investigated. As a result, there are literatures gathered existent KYT sheets. However, a specific design method for KYT sheets has not been established. Due to this problem, it is not possible to produce KYT sheets that reflect actual incidents situations. In hospital A where KYT was introduced, an interview was conducted with nurses who compiled KYT sheets. It was found that when the nurses produced the KYT sheets, they defined the workplace and the work conditions in the KYT sheet without considering medical incidents. A comparison of the workplace and the work conditions were depicted in the KYT sheets by such way with actual incident situations occurred in hospital A was conducted. As a result, the incidents didn’t occur in the work condition depicted in the KYT sheets. Therefore, current KYT sheets do not provide education on incident factors.

An additional problem was that of making the answer to the KYT sheets dependent on nurses. There were no guidelines for identifying hazards and the method for evaluating the ability to identify hazards. Therefore, it has not been possible to confirm whether KYT is effective or not. Table 1 shows the investigation results.

Table 1. The current problem with KYT in the medical service

|Current problem with KYT |Causes of the problem |

|KYT sheets that are based on incidents situations are not |(1)The incident to be represented on the KYT sheet cannot be |

|produced. Therefore, effective KYT for preventing medical |decided. |

|incidents cannot be executed in each hospital. | |

| |(2)The incident factors cannot be reflected as they are |

| |normally observed. |

|A means by which evaluate the ability to identify hazards has |(3)The answer to the KYT sheets is not based on evidence. |

|not been established. | |

In order to execute effective KYT, it is necessary to establish a design method for KYT sheets that addresses the causes of the problem (1) ~ (3) shown in table 1.

PROPOSING A METHOD OF DESINING KYT SHEETS FOR PREVENTING MEDICAL INCIDENTS

Considering the Requirements of KYT

If a design method for KYT sheets that solves the problem shown in table 1 is established, KYT sheets for preventing medical incidents can be produced and effective KYT will be executed. Therefore, the requirements of KYT for solving the causes (1) ~ (3) were considered. Requirements numbers (1) to (3) correspond to causes numbers (1) to (3) shown in table 1.

(1) The incident depicted in the KYT sheet is chosen according to the maximum number of occurring incidents.

(2)-1 The incident factors reflected in the KYT sheet are determined.

(2)-2 The determined incident factors are correctly reflected in the KYT sheets.

(3) The answer to KYT for evaluation the ability to identify hazards is made.

The Incidents as Objects of KYT

In order to fulfill requirements (1) ~ (3), when KYT sheets are produced, the incidents should be referred to. By way of demonstrating the procedure, medication incidents that occurred in hospital A will be analyzed and the result of the analysis will be utilized for producing KYT sheets. However, many types of incidents occur in hospitals and KYT is not an effective means of educating on all types of incidents. For example, KYT is not suited to the educating on the prevention of incidents that occur through a failure to follow the standard practice. For reducing such incidents, teaching standard practice is more effective.

The aim of executing KYT is not teaching standard practice but improving the ability to notice hazards. In this paper, the incidents as objects of KYT are the careless incidents that nurses (who have knowledge and skills) caused, even though they followed standard practice. Therefore, 30 incidents as objects of KYT (over a period of 9 months) are selected from the incidents that occurred in hospital A, and these are analyzed.

Analysis of Medication Incidents and Arrangement of the Results

In order to fulfill the requirements shown above, the medication incidents as objects of KYT were analyzed according to following (1) ~ (3) analysis steps. By analyzing case A as an example, the analysis steps are explained.

[A case example of medication incidents as objects of KYT]

　　Patient A was placed on 2 drips (medicine X and medicine Y) the speeds of which were the same (20m/h). The instructions [change the speed of the main drip (medicine X) from 20ml/h to 60ml/h] was written on a prescription for patient A. Ns. B, who took care of patient A, changed the speed of the drip without confirming the route of the drip before taking a rest. However, Ns. B changed the speed of the wrong drip (medicine Y) from 20ml/h to 60ml/h.

(1) Classifying the medication incidents by similar incidents and counting the number of incidents

A detailed investigation of every medication incident clearly revealed that similar incidents have often occurred. Therefore, the medication incidents that occurred in hospital A can be classified by similar incidents. By classifying the incidents, the number of such incidents can be counted and education for preventing the incidents can be efficiently executed according to the maximum number of occurring incidents.

Medication incidents arise from certain factors. In this paper, the incidents that have the same incident phenomena and same incident factor are defined as similar incidents. When the phenomena of an incident and the incident factor were identified, this study utilized “error modes,” which can represent all errors occurring in a segment of an operation known as a “work element” (Nakajo et al., 1985), and “error factors,” which can represent all causes of medication incidents (Ozaki et al., 2005). The error mode and error factor of case A were “mistake in choice” and “similar appearance or name,” respectively.

In addition, this study classified medication incidents into 9 similar incidents by combining error modes with error factors and counting the number of medication incidents. The number of each similar incident is shown in table 2.

Table 2. Classification of medication incidents by similar incidents and the number of such incidents

|Similar incident No. |Error modes |Error factors |Number |

|1 |Skipping |Scattered information on a prescription |1 |

|2 | |imperfect work attendant on main work |6 |

|3 | |depending on memory |1 |

|4 | |work interruption |1 |

|5 |mistake in counting |repeating similar work |1 |

|6 |mistake in choice |multiple choices |5 |

|7 | |similar appearance or name |10 |

|8 |mistake in perception |bias on knowledge and memory |3 |

|9 | |similar appearance or name |2 |

| | |total |30 |

(2)-1 Analyzing and arranging factors using the P-mSHELL model

An incident arises from certain factors. In order to conduct effect KYT for the prevention of incidents, it is necessary to produce KYT sheets for educating on all factors that induce an incident. If the factors reflected on the KYT sheet are arranged correctly, all of thee factors will be depicted on the KYT sheet.

Therefore, the factors were analyzed using the P-mSHELL model which was originally proposed for use in human factor engineering. The results obtained from analyzing case A are shown in table 3.

Table 3. The result of analyzing factors of case A using the P-mSHELL model

|Items of the P-mSHELL model |Analyzed factors |

|Patient |none |

|Management |none |

|Software |none |

|Hardware |similar route of drip |

|Environment |condition before taking rest |

|Liveware (original) |Action by preconceived ideas, lack of confirming route, |

| |lack of confirming a prescription |

|Liveware (surrounding) |none |

By utilizing the P-mSHELL model, all incident factors can be analyzed. However, the items of the P-mSHELL model, for example, “Patient,” are abstract words. Consequently, if the factors are arranged by utilizing these items of the P-mSHELL model, it is not obvious which factors should be reflected on the KYT sheet. Therefore, the factors analyzed using the P-mSHELL model were classified by similar factors and the items of the P-mSHELL model were embodied. The specific items of the P-mSHELL model are shown in table 4.

Table 4. Items of the P-mSHELL model and specific items

|Items of P-mSHELL |Specific items |Items of P-mSHELL |Specific items |

|Patient |Patient’s condition |Environment |Condition of working |

|Management |Observance of rule | |Condition of nurses’ station |

|Software |Condition of a prescription | |Scattered objects |

| |Rule in hospital |Liveware(original) |Lack of knowledge |

| |Way of working | |Action by preconceived ideas |

| |Order for patient | |Lack of confirming |

|Hardware |Medical instrument | |Psychological condition |

| |Medicine |Liveware |Lack of confirming |

| | |(surrounding) |by more than one person |

| | | | |

| | | |Lack of communication |

By arranging the incident factors in terms of the specific items shown in table 4, the incident factors reflected in the KYT sheet can be clearly understood.

(2)-2 Determining how to represent the incident factors reflected in KYT sheets

At present, when nurses compile KYT sheets, they attempt to conceal the actual incident factors. Furthermore, it is difficult to draw illustrations of the incident factors. Therefore, this study proposes how to represent the incident factors on KYT sheet so that the factors are reflected on the sheet as they are normally observed.

KYT sheets used in the industrial world were investigated in order to understand how to represent the incident factors. As a result, 3 means of representation were found; (a) drawing the factors as illustrations, (b) giving explanation as “condition-setting” and (c) guessing from the condition depicted in the KYT sheet. In addition, specific items of the P-mSHELL model were classified into 3 types of representation so that the incident factors could be easily reflected in the KYT sheet.

(3) Analyzing unsafe behavior and phenomena of the incident in order to construct a “Hazard story”

If there is the answer of KYT that is based on evidence, evaluating the ability to notice hazards can be conducted by comparing the frequency of correct answers. Workers who execute a KYT relate a “Hazard story” which connects factors, behavior, and phenomena, when they discuss the hidden hazard depicted in a KYT sheet. Therefore, a “Hazard story” was constructed by connecting the behavior and phenomena that arise from incident factors analyzed in analysis step (2)-1, and this study defined the “Hazard story” constructed by such method as the answer of KYT.

In order to construct a “Hazard story,” it is necessary to analyze the unsafe behavior and phenomena of an incident that arise from contain incident factors. Therefore, the behavior and phenomena that arose from the incident factors identified in analysis step (2)-1 were analyzed. Furthermore, the detailed order, detailed environmental conditions, and the movement of the person concerned before and after the incident were identified and arranged as complementary information. Table 5 shows a part of the unsafe behavior and phenomena that arose from the incident factors of case A analyzed in analysis step (2)-1.

Table 5. Incident factors, unsafe behavior, and phenomena of case A

|Specific items |Incident factor |Unsafe behavior |Phenomena |

|Medical instrument |Because routes of 2 drips are similar |nurse B chose the wrong drip which was |and nurse B changed the |

| | |different to the drip to be changed |speed of the wrong drip. |

|Lack of |Because nurses B didn’t confirm the instructions |nurse B didn’t notice that he/she had chosen | |

|confirmation |written on the prescription and medicine name |the wrong drip | |

|… |… |… |… |

By utilizing incident factors, unsafe behavior, and phenomena as arranged in table 5, it is easy to construct a “Hazard story”.

In order to produce effective KYT sheets for preventing medical incidents, the result of the analysis should be arranged. This study proposed a list (the “Incident List”) in which the results of the analysis are arranged. Table 6 shows part of an “Incident List” in which the results of analyzing case A are arranged. The numbers (1)~(3) and letters (a)~(c) written on the “Incident List” correspond to the numbers (1)~(3) of the requirements and the analysis steps shown above.

Table 6. A part of an “Incident List”

[pic]

[pic]

Proposing a Design Method for KYT Sheets

This study proposed a design method for KYT sheets fulfilling the requirements of KYT by utilizing “Incident Lists”. The proposed design method for KYT sheets is shown below. The numbers ①~⑤ of the design method correspond to the numbers ①~⑤ of the “Incident List” shown in table 6.

Step 1) Deciding the incident is reflected in the KYT sheet.

“Error modes” and “error factors” of the incident that is reflected in the KYT sheet are determined by considering ① the number of incidents. The incident reflected in the KYT sheet is determined from incidents that have “error modes” and “error factors” determined above.

Step 2) Constructing “Hazard stories” for the answer of KYT

By connecting the ② incident factor, ③ behavior, and ④ phenomena of the incident selected in step 1, the “Hazard story” for the answer of KYT is established.

Step 3) Setting work conditions for the KYT sheet and taking a photograph

The nursing service in which the incident occurred is understood from the “Hazard story” constructed in step 2 and ⑤ complementary information. The photograph showing him/her working in the nursing service is taken with a view to reflecting the working scene as it is normally seen. The work condition is then set so that (a) incident factors drawn as illustrations are reflected in the KYT sheet.

Step 4) Writing “condition-setting”

Both (b) incident factor written in words and the nursing service depicted in the photograph are written as “condition-setting.”

By utilizing both the “Incident List” and the design method for KYT sheets proposed above, it is possible to produce effective KYT sheets for preventing medical incidents.

Application of the Design Method for KYT Sheets Proposed in This Study

A KYT sheet was produced according to the design method for KYT sheets proposed in this study. Application of the resulting KYT sheet is shown below. Since this study took selected case A as an incident to produce a KYT sheet, the results presented in table 6 were considered.

1) Since many incidents are characterized by mistakes in choice as “error modes” and similar appearance or name as “error factors” commonly occur, this study selected an incident that arose from a mistake in choice and similar appearance or name.

2) The “Hazard stories” shown in table 7 were constructed.

Table 7. A part of the “Hazard stories”

|No. |The way to represent the |"Hazard stories" |

| |incident factors | |

|1 |(a) illustration |Because routes of the 2 drips were similar, nurse B chose the wrong drip which was different to the |

| | |drip to be changed drip and nurse B changed the speed of the wrong drip. |

|2 |(c) guess |Because nurse B did not confirm the routes of the drip, nurse B chose wrong drip which was different |

| | |to the drip to be changed drip and nurse B changed the speed of the wrong drip. |

|3 |(c) guess |Because nurse B chose the drip based on preconceived ideas, nurse B forgot to confirm the route of the|

| | |drip and nurse B changed the speed of the wrong drip. |

3) The scene, which shows 2 similar drips and him/her changing the speed of the drip, is depicted in a photograph.

4) “Before taking a rest” as an incident factor and “A nurse changes the speed of the drip” as the nursing service were written as “condition-setting.”

• KYT sheet made according to the design method

Condition-setting: A nurse is changing the speed of the drip before taking a rest.

[pic]

VERIFICATION OF THE EFFECTS OF THE PROPOSED DESIGN METHOD

Evaluation of Improvements in the Ability to Notice Hazards

In order to verify an improvement in the ability to notice hazards using the KYT sheets produced according to the proposed design method, KYT was executed 2 times by 60 nurses. The 60 nurses were divided into 2 groups, which used different procedures for executing KYT. The change in the average number of “Hazard stories” found by nurses is shown in table 8.

Table 8. The change in the average number of “Hazard stories” found

|Nursing career (years) |Average number of "Hazard stories" found on |Average number of "Hazard stories" found on |

| |first attempt |second attempt |

| Junior (1~2) |1.05 |1.75 |

|Intermediate (3~7) |1.24 |1.76 |

|Senior (8 and over) |1.50 |1.75 |

|Total |1.23 |1.75 |

Table 8 shows that the average number of “Hazard stories” found increased on the second attempt. This was particularly noticeable with junior and intermediate nurses for whom the average improved to a level equivalent to that of senior nurses. In addition, a test of population mean difference in paired data was carried out. As a result, the population means difference between the number of “Hazard stories” found on the first and second attempts was significant at the 5% significance level. Therefore, repeat execution of the KYT, using KYT sheets produced according to the method proposed in this study, improved the ability to notice hazards.

Verification of the Effectiveness of the Newly Produced KYT Sheets as a Tool for Education

In order to verify the effectiveness of the newly produced KYT sheets as an education tool, KYT was executed in hospital A and B using 3 different sheets produced according to the proposed method. The procedure of KYT execution was observed. As a result, it was confirmed that nurses to discussed the relevant factors in their work and how to prevent hazards arising from various incident factors. Furthermore, in a questionnaire survey among 44 nurses, 42 nurses answered “I understood deeply that there are many hazards in routine nursing work”. Therefore, the KYT sheets produced using the proposed method are considered to be effective for educating on the prevention of medical incidents.

DISCUSSION

Features of the Method Proposed in This Study

In the past, the production of KYT sheets depended on the ability of nurses who compiled the KYT sheets. As a consequence, the KYT sheets failed to present the conditions of medical incidents correctly, and effective KYT for the prevention of medical incidents was not conducted.

This study proposes an “Incident List” and “a design method for KYT sheets” in order to solve the conventional problems. In the “Incident List,” medication incidents were arranged in terms of similar incidents having the same error modes and error factors, and the number of medication incidents was counted. As a result, the features shown below were obtained.

• The point of education is determined according to the number of medication incidents.

• It is easy to reflect incident factors on KYT sheets because specific items of the P-mSHELL model were classified by means of representation.

• A “Hazard story” was easily constructed since the causes and outcomes of incidents were arranged in the list. Additionally, the effect of KYT was evaluated by regarding it as the answer of KYT.

Furthermore, a design method was proposed with a view to reflecting the routine scene on KYT sheets. Therefore, the objective of KYT, which is to discuss with the aid of KYT sheets the hazards with typical work conditions, was achieved.

The Way to Execute Effective KYT

KYT was executed in hospital A and B using KYT sheets produced according to the proposed method. This study proposes next ways in order to execute Effective KYT.

(1) Group execution

This study compared the results of KYT executed by individuals with those of KYT executed by a group of 4～5 nurses. As a result, with individuals the average number of found “Hazard stories” was 4.5, whereas with the group the average number was 8.8. In addition, this study compared the hazards found by junior nurses with the hazards found by senior nurses. As a consequence, it was confirmed that senior nurses were able to find many hazards from various viewpoints. Therefore, by forming a group composed of nurses who differ in the number of years of nursing experience, effective KYT can be executed.

(2) Appropriate KYT sheets

In order to investigate which sheets should be used in KYT, KYT was executed with KYT sheets produced in another hospital. In other words, in hospital A, KYT was executed with KYT sheets produced in hospital B. As a result, nurses who participated in KYT found only a difference in work style and a difference in medical instruments used. In order to solve the problem illustrated above, it is necessary to produce KYT sheets that show the work condition of each hospital by applying the proposed design method. In order to execute more effective KYT, the nurses who compile KYT sheets should analyze the medical incidents according to the items in the “Incident List”.

CONCLUSION AND FUTURE TASKS

In this study, an “Incident List” for effective KYT sheets for the prevention of medical incidents and a design method for producing KYT sheets based on such lists were proposed. Additionally, KYT was executed with the KYT sheets produced according to the proposed design method and an improvement in nurse’s ability to notice hazards was confirmed. Future tasks will involve applying the proposed design method to falling incidents and devising a means by use KYT as a tool for educating on correct nursing skills.

REFERENCES

1] Nakajo, T. et al., (1985), “Studies of the Fool Proofs in Work System-Assessment for Fool Proofs in Manufacturing-”, Quality, vol.15, pp.41-50

2] Ozaki, I. et al., (2005), “A Study of the Reduction of Accidents in Medication by Error Proofs”, Hospital Management, vol.42, No.3, pp. 361-373

3] Ministry of Health, Labor and Welfare,

4] Japan Industrial Safety & Health Association, (2006), Kiken Yochi Training for Zero Accidents, Japan Industrial Safety & Health Association, Japan

5] Sugiyama, Y., (2006), “Safety Training in Medical Service”, Hospital Management, vol.16, No.3, pp. 189-193

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