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

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 numbers 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 sub-divided 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 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team-working, and three (8.8%) with decision-making. These three sub-categories, 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 sub-categories of non-technical skills may be especially relevant.研究目的：本研究旨在明确致命医疗事故中可归因于非技术技能（Non-Technical Skills）缺失的占比，并通过提出相关培训需求建议，为制定减少此类事故的政策提供支持。 研究设计：本研究对日本医疗安全研究组织（Japan Medical Safety Research Organization）发布的致命医疗事故报告摘要进行逐一评审。由3名经验丰富的临床医师与1名患者安全专家开展评审工作，以判定死亡原因。在最终判定过程中，患者安全专家的意见将被赋予额外权重。 研究场景：本研究共评审了73份致命医疗事故报告摘要。这些报告由日本全国各医疗机构于2010年4月至2013年3月期间提交至日本医疗安全研究组织。 主要与次要结局指标：对致命医疗事故的死亡原因进行评估，将其分为技术技能、非技术技能及疾病自然进展三类。非技术技能进一步细分为情境觉察、决策制定、沟通协作、团队合作、领导力、压力管理及疲劳应对七个子项。 研究结果：总体而言，34例（46.6%）事故的死亡原因被判定为非技术技能缺失，33例（45.2%）为疾病自然进展，2例（5.5%）为技术技能问题。另有2例未能达成一致性判定。对非技术技能相关病例的进一步细分显示，14例（41.2%）存在情境觉察问题，8例（23.5%）存在团队合作问题，3例（8.8%）存在决策制定问题。上述三类子项或其组合被判定为33例（97.1%）非技术技能相关事故的死亡原因。 研究结论：在所纳入的致命医疗事故中，近半数事故的不良事件可归因于非技术技能缺失，这是一项重要的致病因素。提升非技术技能水平或可有效减少医疗事故，且针对非技术技能特定子项的培训可能具有更高的针对性价值。