Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010-2013 national accident reports

Masashi Uramatsu, Yoshikazu Fujisawa, Shinya Mizuno, Takahiro Souma, Akinori Komatsubara, Tamotsu Miki

    Research output: Contribution to journalReview article

    10 Citations (Scopus)

    Abstract

    Objectives: We sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor non-technical skills, and to support development of a policy to reduce number of such accidents by making recommendations about possible training requirements. Design: Summaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination. Setting: A total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013. Primary and secondary outcome measures: The cause of death in fatal medical accidents, categorised into technical skills, non-technical skills and inevitable progress of disease were evaluated. Non-technical skills were further subdivided into situation awareness, decision making, communication, team working, leadership, managing stress and coping with fatigue. Results: Overall, the cause of death was identified as non-technical skills in 34 cases (46.6%), disease progression in 33 cases (45.2%) and technical skills in two cases (5.5%). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified as 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team working and three (8.8%) with decision making. These three subcategories, or combinations of them, were identified as the cause of death in 33 cases (97.1%). Conclusions: Poor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for reducing accidents, and training in particular subcategories of non-technical skills may be especially relevant.

    Original languageEnglish
    Article numbere013678
    JournalBMJ Open
    Volume7
    Issue number2
    DOIs
    Publication statusPublished - 2017 Feb 1

    Fingerprint

    Accidents
    Japan
    Cause of Death
    Patient Safety
    Biomedical Research
    Decision Making
    Organizations
    Safety
    Policy Making
    Fatigue
    Disease Progression
    Communication
    Outcome Assessment (Health Care)
    Delivery of Health Care
    Weights and Measures

    ASJC Scopus subject areas

    • Medicine(all)

    Cite this

    Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010-2013 national accident reports. / Uramatsu, Masashi; Fujisawa, Yoshikazu; Mizuno, Shinya; Souma, Takahiro; Komatsubara, Akinori; Miki, Tamotsu.

    In: BMJ Open, Vol. 7, No. 2, e013678, 01.02.2017.

    Research output: Contribution to journalReview article

    Uramatsu, Masashi ; Fujisawa, Yoshikazu ; Mizuno, Shinya ; Souma, Takahiro ; Komatsubara, Akinori ; Miki, Tamotsu. / Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010-2013 national accident reports. In: BMJ Open. 2017 ; Vol. 7, No. 2.
    @article{e0fcc1fcf9ae470a995233f865d5a005,
    title = "Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010-2013 national accident reports",
    abstract = "Objectives: We sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor non-technical skills, and to support development of a policy to reduce number of such accidents by making recommendations about possible training requirements. Design: Summaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination. Setting: A total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013. Primary and secondary outcome measures: The cause of death in fatal medical accidents, categorised into technical skills, non-technical skills and inevitable progress of disease were evaluated. Non-technical skills were further subdivided into situation awareness, decision making, communication, team working, leadership, managing stress and coping with fatigue. Results: Overall, the cause of death was identified as non-technical skills in 34 cases (46.6{\%}), disease progression in 33 cases (45.2{\%}) and technical skills in two cases (5.5{\%}). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified as 14 cases (41.2{\%}) of problems with situation awareness, eight (23.5{\%}) with team working and three (8.8{\%}) with decision making. These three subcategories, or combinations of them, were identified as the cause of death in 33 cases (97.1{\%}). Conclusions: Poor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for reducing accidents, and training in particular subcategories of non-technical skills may be especially relevant.",
    author = "Masashi Uramatsu and Yoshikazu Fujisawa and Shinya Mizuno and Takahiro Souma and Akinori Komatsubara and Tamotsu Miki",
    year = "2017",
    month = "2",
    day = "1",
    doi = "10.1136/bmjopen-2016-013678",
    language = "English",
    volume = "7",
    journal = "BMJ Open",
    issn = "2044-6055",
    publisher = "BMJ Publishing Group",
    number = "2",

    }

    TY - JOUR

    T1 - Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010-2013 national accident reports

    AU - Uramatsu, Masashi

    AU - Fujisawa, Yoshikazu

    AU - Mizuno, Shinya

    AU - Souma, Takahiro

    AU - Komatsubara, Akinori

    AU - Miki, Tamotsu

    PY - 2017/2/1

    Y1 - 2017/2/1

    N2 - Objectives: We sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor non-technical skills, and to support development of a policy to reduce number of such accidents by making recommendations about possible training requirements. Design: Summaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination. Setting: A total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013. Primary and secondary outcome measures: The cause of death in fatal medical accidents, categorised into technical skills, non-technical skills and inevitable progress of disease were evaluated. Non-technical skills were further subdivided into situation awareness, decision making, communication, team working, leadership, managing stress and coping with fatigue. Results: Overall, the cause of death was identified as non-technical skills in 34 cases (46.6%), disease progression in 33 cases (45.2%) and technical skills in two cases (5.5%). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified as 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team working and three (8.8%) with decision making. These three subcategories, or combinations of them, were identified as the cause of death in 33 cases (97.1%). Conclusions: Poor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for reducing accidents, and training in particular subcategories of non-technical skills may be especially relevant.

    AB - Objectives: We sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor non-technical skills, and to support development of a policy to reduce number of such accidents by making recommendations about possible training requirements. Design: Summaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination. Setting: A total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013. Primary and secondary outcome measures: The cause of death in fatal medical accidents, categorised into technical skills, non-technical skills and inevitable progress of disease were evaluated. Non-technical skills were further subdivided into situation awareness, decision making, communication, team working, leadership, managing stress and coping with fatigue. Results: Overall, the cause of death was identified as non-technical skills in 34 cases (46.6%), disease progression in 33 cases (45.2%) and technical skills in two cases (5.5%). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified as 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team working and three (8.8%) with decision making. These three subcategories, or combinations of them, were identified as the cause of death in 33 cases (97.1%). Conclusions: Poor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for reducing accidents, and training in particular subcategories of non-technical skills may be especially relevant.

    UR - http://www.scopus.com/inward/record.url?scp=85013436262&partnerID=8YFLogxK

    UR - http://www.scopus.com/inward/citedby.url?scp=85013436262&partnerID=8YFLogxK

    U2 - 10.1136/bmjopen-2016-013678

    DO - 10.1136/bmjopen-2016-013678

    M3 - Review article

    VL - 7

    JO - BMJ Open

    JF - BMJ Open

    SN - 2044-6055

    IS - 2

    M1 - e013678

    ER -