"LATEST-CAUSE ANALYSIS" AS AN APPROACH FOR MAKING PREVENTIVE MEASURES. --FROM THE EXPERIENCES OF 2,000 CASES, REPORTED TO "MEDICAL ACCIDENT INVESTIGATION SYSTEM / JAPAN"-- Sosuke Kimura* 1 1Japan Medical Safety Research Organization, Tokyo, Japan

  Introduction: To draw up preventive measures from the accident reports is a major product of the “Medical Accident Investigation System / Japan”.

The approach to the accident analysis has been somewhat different from the conventional “Root-cause analysis”, it is to compare the latest causes of each similar accidents.

  Methods: The accident reports were sorted to a group of similar cases, those will be the target accidents under a theme. Among those cases, “Turning-point” of accident (a complex of elements which branched the clinical course towards the accident) was applied on each case. Those turning-points with its elements (Patient condition, Medical care provided and the Environment of the hospital), were compared and reviewed by the specialists (Dr/Ns, Specialist of subject field). This comparative analysis will elucidate common characteristics of target accidents. Through these processes, we analyze actively related, latest causes of the accident (causes which influence directly to the accident, as a trigger.) and make up concreate preventive measures specific to the target accidents.

  Results: At this point (August. 2023.), the booklets “Recommendations for the prevention of recurrence of the medical accident”, under the 17 themes were published in Japan. Some of them are “Central Venous Catheterization”, “Acute Pulmonary Thromboembolism”, “Anaphylaxis”, “Early Post-Tracheostomy Troubles”, “Laparoscopic Cholecystectomy”, “Catheter Ablation”, “Erroneous medication and administration of medicine” and “Airway Obstruction due to Cervical Surgery", etc. Each recommendation consists of specific on the concrete preventives for the target medical accident, resulted from the analysis of 5~20 cases of death related to the accident.

  Method of making up preventive measures from accident report, "Root cause analysis" is essential, but our method "Comparative Latest cause analysis" is more case specific and cocrete in the clinical scene. These two approaches combined, will build up a significantly effective preventive measures.