Development of a scoring system to quantify errors from semantic characteristics in incident reports.

OBJECTIVES: Incident reporting systems are widely used to identify risks and enable organisational learning. Free-text descriptions contain important information about factors associated with incidents. This study aimed to develop error scores by extracting information about the presence of error factors in incidents using an original decision-making model that partly relies on natural language processing techniques. METHODS: We retrospectively analysed free-text data from reports of incidents between January 2012 and December 2022 from Nagoya University Hospital, Japan. The sample data were randomly allocated to equal-sized training and validation datasets. We conducted morphological analysis on free text to segment terms from sentences in the training dataset. We calculated error scores for terms, individual reports and reports from staff groups according to report volume size and compared these with conventional classifications by patient safety experts. We also calculated accuracy, recall, precision and F-score values from the proposed 'report error score'. RESULTS: Overall, 114 013 reports were included. We calculated 36 131 'term error scores' from the 57 006 reports in the training dataset. There was a significant difference in error scores between reports of incidents categorised by experts as arising from errors (p<0.001, d=0.73 (large)) and other incidents. The accuracy, recall, precision and F-score values were 0.8, 0.82, 0.85 and 0.84, respectively. Group error scores were positively associated with expert ratings (correlation coefficient, 0.66; 95% CI 0.54 to 0.75, p<0.001) for all departments. CONCLUSION: Our error scoring system could provide insights to improve patient safety using aggregated incident report data.

Japanese Patient Engagement Promotion Training (J-PEPT): Learning course on the implementation strategy of patient engagement.

Patient engagement for patient safety is emphasized in recent years. Therefore, the Committee on Quality and Patient Safety of the Japan Primary Care Association developed a Japanese Patient Engagement Promotion Training (J-PEPT) course. J-PEPT promotes to facilitate the implementation of PE strategies and contributes to nationwide dissemination for patient safety.

Association of sleep quality with duty hours, mental health, and medical errors among Japanese postgraduate residents: a cross-sectional study.

Long duty hours (DH) impair sleep and negatively affect residents' health and medical safety. This cross-sectional study investigated the association among residents' DH, sleep duration, insomnia, sleep impairment, depressive symptoms, and self-reported medical errors among 5579 residents in Japan who completed the General Medicine In-Training Examination (2021) and participated in the training-environment survey. Weekly DH was classified under seven categories. Sleep duration and insomnia symptoms, from the Athens Insomnia Scale, were analysed to determine sleep impairment; depressive symptoms and medical errors were self-reported. Among 5095 residents, 15.5% slept < 5 h/day, and 26.7% had insomnia. In multivariable analysis, compared with ≥ 60 and < 70, DH ≥ 90 h/week associated with shorter sleep duration and worsen insomnia symptoms. Shorter durations of sleep and more intense symptoms of insomnia were associated with increased depressive symptoms. Medical errors increased only among residents with insomnia, but were not associated with sleep duration. DH > 90 h/week could lead to shorter sleep duration, worsen insomnia symptoms, and negatively impact well-being and medical safety. There was no significant association between sleep duration and medical errors; however, insomnia conferred an increased risk of medical errors. Limiting DH for residents to avoid excessive workload can help improve resident sleep, enhance resident well-being, and potentially reduce insomnia-associated medical errors.

Safety culture survey among medical residents in Japan: a nationwide cross-sectional study.

PURPOSE: This study aimed to examine safety culture among Japanese medical residents through a comparative analysis of university and community hospitals and an investigation of the factors related to safety culture. METHOD: This nationwide cross-sectional study used a survey to assess first and second-year medical residents' perception of safety culture. We adapted nine key items from the Safety Awareness Questionnaire to the Japanese training environment and healthcare system. Additionally, we explored specific factors relevant to safety culture, such as gender, year of graduation, age, number of emergency room duties per month, average number of admissions per day, incident experience, incident reporting experience, barriers to incident reporting and safety culture. We analysed the data using descriptive statistics and multivariate logistic regression analysis. RESULTS: We included 5289 residents (88.6%) from community training hospitals and 679 residents (11.4%) from university hospitals. A comparative analysis of safety culture between the two groups on nine representative questions revealed that the percentage of residents who reported a positive atmosphere at their institution was significantly lower at university hospitals (81.7%) than at community hospitals (87.8%) (p<0.001). The other items were also significantly lower for university hospital residents. After adjusting for multivariate logistic analysis, university hospital training remained significantly and negatively associated with all nine safety culture items. Furthermore, we also found that university hospital residents perceived a significantly lower level of safety culture than community hospital residents. IMPLICATIONS: Further research and discussion on medical professionals' perception of safety culture in their institutions as well as other healthcare professionals' experiences are necessary to identify possible explanations for our findings and develop strategies for improvement.

Association between prolonged weekly duty hours and self-study time among residents: a cross-sectional study.

PURPOSE: In 2024, the Japanese government will enforce a maximum 80-hour weekly duty hours (DHs) regulation for medical residents. Although this reduction in weekly DHs could increase the self-study time (SST) of these residents, the relationship between these two variables remains unclear. The aim of the study was to investigate the relationship between the SST and DHs of residents in Japan. METHODS: In this nationwide cross-sectional study, the subjects were candidates of the General Medicine In-Training Examination in the 2020 academic year. We administered questionnaires and categorically asked questions regarding daily SST and weekly DHs during the training period. To account for hospital variability, proportional odds regression models with generalized estimating equations were used to analyse the association between SST and DHs. RESULTS: Of the surveyed 6117 residents, 32.0% were female, 49.1% were postgraduate year-1 residents, 83.8% were affiliated with community hospitals, and 19.9% worked for ≥80 hours/week. Multivariable analysis revealed that residents working ≥80 hours/week spent more time on self-study than those working 60-70 hours/week. Conversely, residents who worked <50 hours/week spent less time on self-study than those who worked 60-70 hours/week. The factors associated with longer SST were sex, postgraduate year, career aspiration for internal medicine, affiliation with community hospitals, academic involvement, and well-being. CONCLUSION: Residents with long DHs had longer SSTs than residents with short DHs. Future DH restrictions may not increase but rather decrease resident SST. Effective measures to encourage self-study are required, as DH restrictions may shorten SST.

Impact of duty hours on competency-related knowledge acquisition among community hospital residents.

Background: The effect of duty hour (DH) restrictions on postgraduate residents' acquisition of clinical competencies is unclear. We evaluated the relationship between DHs and competency-related knowledge acquisition using the General Medicine In-training Examination (GM-ITE). Methods: We conducted a multicenter, cross-sectional study of community hospital residents among 2019 GM-ITE examinees. Self-reported average DHs per week were classified into five DH categories and the competency domains were classified into four areas: symptomatology and clinical reasoning (CR), physical examination and clinical procedure (PP), medical interview and professionalism (MP), and disease knowledge (DK). The association between these scores and DHs was examined using random-intercept linear models with and without adjustment for confounding factors. Results: We included 4753 participants in the analyses. Of these, 31% were women, and 49.1% were in the postgraduate year (PGY) 2. Mean CR and MP scores were lower among residents in Category 1 (<50 h) than in residents in Category 3 (≥60 and <70 h; reference group). Mean DK scores were lower among residents in Categories 1 and 2 (≥50 and <60 h) than in the reference group. PGY-2 residents in Categories 1 and 2 had lower CR scores than those in Category 3; however, PGY-1 residents in Category 5 showed higher scores. Conclusions: The relationship between DHs and each competency area is not strictly linear. The acquisition of knowledge of physical examination and clinical procedures skills in particular may not be related to DHs.

Relationship between COVID-19 care and burnout among postgraduate clinical residents in Japan: a nationwide cross-sectional study.

OBJECTIVE: The relationship between the care of patients with COVID-19 and mental health among resident physicians in Japan is imperative for ensuring appropriate care of patients with COVID-19 and should be clarified. We herein assessed the relationship between the care of patients with COVID-19 and mental health among postgraduate year 1 (PGY-1) and PGY-2 resident physicians and factors associated with mental health. DESIGN: This nationwide cross-sectional study analysed data obtained using the clinical training environment self-reported questionnaire. SETTING: An observational study across Japan among resident physicians (PGY-1 and PGY-2) from 583 teaching hospitals. PARTICIPANTS: Examinees who took the general medicine in-training examination of academic year 2020. PRIMARY AND SECONDARY OUTCOME MEASURES: The Patient Health Questionnaire and Mini-Z 2.0 were used to assess mental health, and experience of caring for patients with COVID-19 was divided into three groups (none, 1-10 and ≥11). The prevalence of mental conditions in the three groups was compared using the 'modified' Poisson generalised estimating equations by adjusting for prefecture-level, hospital-level and resident-level variables. RESULTS: Of the 5976 participants analysed, 50.9% were PGY-1. The prevalence of burnout was 21.4%. Moreover, 47.0% of all resident physicians had no experience in the care of patients with COVID-19. The well-experienced group accounted for only 7.9% of the total participants. A positive association was found between the number of caring patients with COVID-19 and burnout (prevalence ratio 1.25; 95% CI 1.02 to 1.53). Moreover, the shortage of personal protective equipment was identified as a major contributor to burnout (prevalence ratio 1.60; 95% CI 1.36 to 1.88). CONCLUSIONS: Resident physicians who experienced more care of patients with COVID-19 had slightly greater burnout prevalence than those who did not. Approximately half of resident physicians did not participate in the care of patients with COVID-19, which posed a challenge from an educational perspective.

Nationwide survey on Japanese residents' experience with and barriers to incident reporting.

The ability of any incident reporting system to improve patient care is dependent upon robust reporting practices. However, under-reporting is still a problem worldwide. We aimed to reveal the barriers experienced while reporting an incident through a nationwide survey in Japan. We conducted a cross-sectional survey. All first- and second-year residents who took the General Medicine In-Training Examination (GM-ITE) from February to March 2021 in Japan were selected for the study. The voluntary questionnaire asked participants regarding the number of safety incidents encountered and reported within the previous year and the barriers to reporting incidents. Demographics were obtained from the GM-ITE. The answers of respondents who indicated they had never previously reported an incident (non-reporting group) were compared to those of respondents who had reported at least one incident in the previous year (reporting group). Of 5810 respondents, the vast majority indicated they had encountered at least one safety incident in the past year (n = 4449, 76.5%). However, only 2724 (46.9%) had submitted an incident report. Under-reporting (more safety incidents compared to the number of reports) was evident in 1523 (26.2%) respondents. The most frequently mentioned barrier to reporting an incident was the time required to file the report (n = 2622, 45.1%). The barriers to incident reporting were significantly different between resident physicians who had previously reported and those who had never previously reported an incident. Our study revealed that resident physicians in Japan commonly encounter patient safety incidents but under-report them. Numerous perceived and experienced barriers to reporting remain, which should be addressed if incident reporting systems are to have an optimal impact on improving patient safety. Incident reporting is essential for improving patient safety in an institution, and this study recommends establishing appropriate interventions according to each learner's barriers for reporting.

Development of a Novel Scoring System to Quantify the Severity of Incident Reports: An Exploratory Research Study.

Incident reporting systems have been widely adopted to collect information about patient safety incidents. Much of the value of incident reports lies in the free-text section. Computer processing of semantic information may be helpful to analyze this. We developed a novel scoring system for decision making to assess the severity of incidents using the semantic characteristics of the text in incident reports, and compared its results with experts' opinions. We retrospectively analyzed free-text data from incident reports from January 2012 to September 2021 at Nagoya University Hospital, Aichi, Japan. The sample was allocated to training and validation datasets using the hold-out method. Morphological analysis was used to segment terms in the training dataset. We calculated a severity term score, a severity report score and severity group score, by report volume size, and compared these with conventional severity classifications by patient safety experts and reporters. We allocated 96,082 incident reports into two groups. We calculated 1,802 severity term scores from the 48,041 reports in the training dataset. There was a significant difference in severity report score between reports categorized as severe and not severe by experts (95% confidence interval [CI] -0.83 to -0.80, p < 0.001, d = 0.81). Severity group scores were positively associated with severity ratings from experts and reporters (correlation coefficients 0.73 [95% CI 0.63-0.80, p < 0.001] and 0.79 [95% CI 0.71-0.85, p < 0.001]) for all departments. Our severity scoring system could therefore contribute to better organizational patient safety.

Association between mental health and duty hours of postgraduate residents in Japan: a nationwide cross-sectional study.

The new duty hour (DH) limit for doctors in Japan will begin in 2024, setting the maximum DHs for postgraduate residents at approximately 80 h weekly. To set appropriate limits, understanding the association between DHs and psychological health is necessary. Thus, we assessed the relationship between residents' psychological health and DHs. We conducted a cross-sectional study involving examinees of the General Medicine In-training Examination 2020. Mental health outcomes were measured dichotomously using the Patient Health Questionnaire-2 for depression and Mini-Z 2.0, for burnout, stress, and satisfaction. Weekly DHs were measured in seven categories at 10-h intervals. The prevalence ratios (PRs) between the DH categories were estimated for each outcome. Of the 6045 residents who provided data on DHs and psychological outcomes, 37.3% showed signs of depression, 21.6% experienced burn out, and 39.2% were highly stressed. In contrast, 62.3% were highly satisfied with their training. Proportions of burnout were higher among residents in Category 6 (≥ 90 and < 100 h; PR 1.36; 95% CI 1.11-1.66) and Category 7 (≥ 100 h; PR 1.36; 95% CI 1.10-1.68) compared with residents in Category 3 (≥ 60 and < 70 h; reference). The results partially support the weekly 80-h DH limit in terms of resident well-being.

Impact of the hospitalist system on inpatient mortality and length of hospital stay in a teaching hospital in Japan: a retrospective observational study.

OBJECTIVE: To examine the differences in the quality of care among inpatients before and after the introduction of the hospitalist system. DESIGN: A retrospective observational study. SETTING: A community teaching hospital in Japan. PARTICIPANTS: The inpatients admitted between the preintervention (January-December 2018) and 1-year intervention (January-December 2019) periods. There were 8508 and 8788 inpatients in 2018 and 2019, respectively. INTERVENTIONS: The study compared the lengths of hospital stay and mortality among inpatients between the pre-and post-intervention (2018 and 2019) periods concerning the introduction of a hospital medicine department. OUTCOME MEASURES: The primary objective was to evaluate and compare the in-hospital mortality and the length of stay (LOS) between 2018 and 2019. The secondary objective was to identify the characteristics of hospitalists and non-hospitalists in the system. RESULTS: The LOS was significantly reduced after the introduction of the hospital medicine department (adjusted difference, -0.659 days; 95% CI -1.118 to -0.136, p=0.01). There were no differences in the adjusted mortalities between the two periods. CONCLUSIONS: To the best of our knowledge, our study is the first involving a teaching hospital in Japan to reveal that the hospitalist system had a positive effect on the efficiency of inpatient care by shortening the LOS. Further studies are needed to clarify other benefits related to the introduction of the hospital medicine department in Japan.

Complexity of the Diagnosis of COVID-19 in the Context of Pandemicity: Need for Excellence in Diagnostic Acumen.

Coronavirus disease 2019 (COVID-19) is a highly infectious disease that has caused a pandemic devastating many countries worldwide. It is a complex and multifaceted disease with a unique coronavirus etiology, pathogenesis, zoonotic, and human-to-human transmission, causing acute respiratory distress syndrome with high mortality. Accurate and timely diagnosis is of utmost importance. In this study, we discussed the complexities of COVID-19 diagnostic elements in the context of pandemicity, drawing from our awareness, observations, and lessons learned from two previous coronavirus pandemics, namely SARS-CoV (severe acute respiratory syndrome coronavirus) in 2002 and MERS-CoV (Middle East respiratory syndrome-related coronavirus) in 2012, and how they applied to the diagnosis of COVID-19 today. Diagnosis of COVID-19 takes place without physician-patient personal contact due to isolation or quarantine or in the hospital setting, emergency units, and critical care units with the cumbersome barriers of personal protective equipment. Technical diagnosis is important, but we also emphasized the human impact of diagnosing COVID-19. Conveying the diagnosis of a critical disease to patients and families requires aspects of excellence in professionalism: ethics, empathy, and humility. Diagnostic skills in COVID-19 should extend to prognostication for patients suffering at the end of life, so that they will not be deprived of high-quality palliative care and comfort.

Pharmacists can improve diagnosis and help prevent diagnostic errors.

We present two cases that highlight the role of pharmacists in the diagnostic process and illustrate how a culture of safety and teamwork between pharmacists and physicians can help prevent diagnostic errors.

Healthcare use and RT-PCR testing during the first wave of the COVID-19 pandemic in Japan.

BACKGROUND: Rapid testing, tracing, and isolation among symptomatic patients are the standard for controlling the COVID-19. However, during spring 2020, Japan employed a RT-PCR test policy by using a guideline, which was used for the public to visit hospitals or clinics when they had mild symptoms for 4 days or longer ("4-day rule") among low-risk patients. It is unknown of patients' experience of healthcare use and testing during the period under the guideline. Thus, we investigated the healthcare visiting and testing among patients who developed cold-like symptoms during the period. METHODS: Our survey was conducted online in September 2020 to a nationally representative sample of adults throughout Japan. We investigated the public's understanding of the guideline. In addition, we asked their experience with healthcare use and testing if they had noticed new-onset cold-like symptoms. RESULTS: Of 2,137 people surveyed, 1,698 (79.5%) recognized the guidelines, but 422 people (19.7%) misunderstood. There were 144 (6.7% of 2,137 people) who developed cold-like symptoms, and many of them experienced difficulties in getting through telephone calls to a public health center, and 25 (17% of 144 people) visited healthcare institutions. Of these 25 symptomatic patients, 15 (60%) could not receive testing because of decisions by physicians (14 patients) or a local public health center (1 patient). CONCLUSION: There was a low use of healthcare and testing among symptomatic patients during the first wave of the pandemic in Japan. Testing capacity should be increased to provide effective care for patients with suspected COVID-19 in Japan.

Current Status and Future Trend of Dominant Commercial Reverse Osmosis Membranes.

Since 2000, seawater reverse osmosis method has been a dominant desalination technology against the distillation method in the global market. The large project called "Mega-SWRO" (half mega-ton per day and larger) plant in the Middle East is quite popular making full use of the combination with solar energy. Today, the price of desalinated water is affordable at as low as $0.28/m3 to $0.53/m3. Likewise, dominant commercial reverse osmosis membrane is a cross-linked fully aromatic polyamide composite membrane-spiral wound element including FT-30 (DuPont Water Solution) and UTC-80 (Toray Industries., Inc., Otsu, Shiga, Japan). The said membranes are much superior in terms of performance compared to the cellulose triacetate membranes-hollow fiber for variety of applications including seawater desalinations, brackish water desalination, wastewater reuse, ultra-pure production for semiconductor, home-use water purifier, etc. SWCC of Saudi Arabia has announced that it intends to shift from cellulose triacetate hollow fiber to spiral wound RO membranes at all of its plants. Furthermore, the state-sponsored R&D on membrane and membrane process has been put into practice in major countries, including Japan and Korea, which contributed to the progress of membrane science and membrane process, suitable for spiral-wound polyamide membranes. SWCC has announced their plans for SWRO, mainly focusing on brine mining to obtain precious materials from the brine of SWRO. New and innovative brine-mining technology has been introduced for green desalination.

Incident reporting among physicians-in-training in Japan: A national survey.

BACKGROUND: Incident reporting can inform hospital safety. However, under-reporting is preventing this. METHODS: We conducted a nationwide survey among Japanese physicians-in-training by including a questionnaire in the General Medicine In-Training Examination to assess incident reporting behavior and participation in patient safety lectures. RESULTS: Responses of 6,164 physicians-in-training indicated that although 78% had attended patient safety lectures, 44% had not submitted an incident report in the previous year and 40.6% did not know how to submit an incident report. CONCLUSIONS: The discrepancy between attendance at safety courses and incident reporting behavior must be addressed to improve hospital safety.

Rare presentation of Graves' disease with myalgia: A case report.

A 42-year-old woman presented with myalgia, which ameliorated a week after treatment. She was diagnosed with Graves' disease. The presence of concomitant autoimmune diseases is important considerations for patients with Graves' disease presenting with myalgia. Thyrotoxicosis should be included as a rare differential diagnosis for myalgia.

Epidural abscess and spondylitis caused by Veillonella parvula in a man on hemodialysis.

Veillonella species rarely cause serious infections, but the incidence of infection has been increasing among immunocompromised individuals. This case of an epidural abscess and spondylitis caused by Veillonella parvula in a hemodialysis patient illustrates the importance of performing anaerobic blood culture in immunocompromised patients with signs of infection.

Ceftriaxone-associated pseudolithiasis.

Ceftriaxone-associated pseudolithiasis.

Kushiyaki-related Streptococcus suis meningitis with ventriculitis: A case report.

Streptococcus suis causes a zoonotic disease that commonly manifests as meningitis. People handle pork or its derivatives are at a high risk of infection. Handwashing and donning personal protective equipment are the practical preventive measures.