Table 4. Human or systemic contributory factors and solutions related to choking.
| Code | Example sub-codes of solutions |
|---|---|
| Sudden turn in underlying disease (n = 10, 14.7%) | ・Not applicable as choking was unavoidable |
| Inadequate checking (n = 66, 97.1%) | ・Do not look away while the patient is eating |
| ・Use a biological monitor | |
| Misperception of risk (n = 65, 95.6%) | ・Pay more attention using the observation system or visit the patient’s room more frequently |
| ・Conduct appropriate patient risk assessment before eating or fasting | |
| ・Gain the ability to conduct a risk assessment | |
| Poor instructions or procedures (n = 51, 75.0%) | ・Conduct appropriate patient risk assessment before eating or fasting |
| ・Ensure appropriate patient/family education procedure | |
| Inadequate coordination (n = 47, 69.1%) | ・Keep a comfortable and safe position during eating or sleeping |
| ・Select appropriate texture of diet | |
| ・Collect information about eating habits at home from the family | |
| Inadequate environment (n = 29, 42.6%) | ・Keep medical care equipment away from the patient |
| ・Move to a room that allows for easier observation, not a private room | |
| Lack of communication among staff (n = 19, 27.9%) | ・Share risk among staff using a written document containing the patient’s choking-associated factors |
| Non-compliance with rules | ・Re-check the manual |
| (n = 10, 14.7%) | ・Follow the doctor’s instructions |
| Staff/time shortage/busyness (n = 8, 11.8%) | ・Manage time/staff |
| Inadequate medication management (n = 7, 10.3%) | ・To avoid over-sedation, reschedule medicine time and provide adequate monitoring, or adjust dosage |
| ・Reconsider administration route or treatment | |
| Unfamiliarity with the task | ・Continue doing the task under supervision |
| (n = 7, 10.3%) | |
| Educational mismatch of person and task (n = 7, 10.3%) | ・Obtain knowledge about the task |
aRCA, Root cause analysis.
bNumber (%).
cError-producing conditions were multiple choices.