A study of the causes of incidents/accidents at Facility A, a facility for children with severe motor and intellectual disabilities

Abstract

Facilities for minors with severe developmental and physical disabilities are typically care facilities that provide personal/medical care and instruction to facilitate assisted living for minors with severe developmental and motor disabilities. There are 115 such facilities in Japan as of April 1, 2006. Those being cared for span a wide range of ages; there is also a growing trend for them to require increasingly sophisticated medical care.

Previous studies have reported that medication errors involving medications to be taken internally make up the largest number of incidents/accidents that have occurred at these facilities. There are also reports that a wide variety of unexpected accidents take place in the everyday living environment.

This study focused on Facility A, which has most of the features typical of such a facility in Japan, analyzing written reports on the incidents/accidents that have taken place there over a 3-year period to determine their causes.

An analysis of the reports on all 140 incidents/accidents 　found a significant decrease in the number of incidents/accidents in 2008. A monthly breakdown showed that the greatest number of incidents/accidents tended to occur during the time of year when employee assignments change due to transfers and other factors. Incidents/accidents relating to medical care showed a relative decline, but injuries including fractures were on the rise.

Those injured in these incidents/accidents were not limited to residents, but also included minors at the facility for short stays and day use. This study also revealed that members of facility staff have also been injured in incidents/accidents.