がん化学療法の実施に関するインシデントを再現した実地講習会のインシデント削減効果の評価

Abstract

Incidents involving cancer chemotherapies may result in a critical situation. We analyzed the incident reports involving enforcement of cancer chemotherapies in terms of frequency and risk. Thereafter, we implemented practical training based on the analysis for preventing incidents.The incidence of “medication error” was the highest in frequency at 43％, followed by “line management error” 30％ and “inspected error” 27％. After training, the number of incident reports in 2009 involving enforcement of cancer chemotherapies decreased by 45％, from 40 to 22 cases. The incidence per ward nurse involving enforcement of cancer chemotherapies was significantly higher in the non-participants (17/124, 0.137) than in the participants (5/125, 0.040) of the training.The results of questionnaires gathered from the participants indicated that a lack of knowledge about the antineoplastic was the chief cause of these incidents. Our findings suggest that practical training in consideration of the frequency and risk is effective for preventing incidents.