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Department of Safety Management
Masaaki Ito, Kiyotaka Yoh, Naoto Gotohda, Wakana Kitazawa, Hiromi Fujita, Masahito Yonemura, Shinya Motonaga, Ryuko Shimoda, Namiko Aoshima,
Keiji Okinaka, Yukie Endo, Tatsuhiko Kotabe, Satoshi Saito, Akira Shinohara, Go Sato, Keisei Nakamura, Raika Miyahira, Miyuki Tango
Introduction
- Office of Clinical Safety
The Office of Clinical Safety was established as the department responsible for cross organizational safety management in our hospital to provide the best medical service and care for cancer patients.
- Office of Infection Control and Prevention
Routine activities
- Office of Clinical Safety
Since 2016, two full-time staff members (a pharmacist and a nurse) have been working in the Office of Clinical Safety to strengthen the organization. And we have established a committee to introduce new high-level medical technology to the hospital. The Office's routine activities include the review and analysis of all incident cases in the hospitals. The criteria for reporting adverse events have been revised. In addition, contingency plans for serious incidents are established and communicated to all staff. In addition, staff physicians conduct medical record reviews of all in-hospital deaths and chair mortality and morbidity conferences. A rapid response system has been established to support emergency care. A prompt in-hospital case review meeting was held for two cases to respond to medical accident investigation systems.
- Office of Infection Control and Prevention
Our missions include:
- Developing infection control policies and in-hospital guidelines
- Managing the surveillance system of healthcare-associated infections and drug-resistant bacteria to prevent outbreaks of infectious diseases
- Maintaining manuals regarding infection control and antimicrobial stewardship
- Inspecting and improving the quality of the hospital environment using ward rounds
- Inspecting and improving compliance with hand hygiene and other infection control measures using ward rounds
- Offering consulting services regarding infection control problems
- Preventing and managing needlestick injuries
- Vaccinating staff with insufficient protective immunity
- Planning the provision of employee education and educational campaigns to promote infection control and antimicrobial stewardship
- Planning conferences among regional hospitals to promote the improvement of infection control in each hospital
- Promoting antimicrobial stewardship
- Inspecting and promoting the proper disposal of medical waste
・In 2024, our activities focused on promoting vaccination for cancer patients, improving hand hygiene compliance rates, preventing the spread of COVID-19, addressing facility-related concerns such as Legionella in tap water, and preparing for evaluation by the Japan Council for Quality Health Care.
Research activities
- Office of Clinical Safety
Total number of incident report was 5,964；557 cases (10%) from doctors, 4,492 cases(75%) from nurses, 343cases (6%) from pharmacists, 134 cases (2%)from radiological technicians, 133 cases (2%) from laboratory technicians, 45 cases (1%) from nutritionists, 58 cases (1%) from clerical staff, 5 cases (<1%) from CRC, 197 cases (3%) from others. The fall rate of inpatients was 0.223%, and 28.8% of them were due to medical staff factors. Two medical safety reports were submitted to the PMDA during this period.
- Office of Infection Control and Prevention
We hold weekly interdisciplinary research meetings to support ongoing and emerging studies. Recent research initiatives include:
・Evaluating risk factors for false positives in HIV screening tests
・Analyzing trends in COVID-19 antiviral prescriptions
・Assessing the efficacy of rapid microbial identification devices
・Assessing the characteristics and risk factors of Staphylococcus aureus bacteremia in cancer patients
We have also initiated activities to promote vaccination for cancer patients and will continue conducting questionnaire surveys to evaluate the impact of these efforts.
Education
- Office of Clinical Safety
During this period, there were two lectures about safety management in the NCCHE. One was the Medical Safety Management System and Case Reports, and the other was the lecture on “Medical Safety and Related Laws”, “Emergency Response 1: Until the AED arrives”, “Emergency Response 2: How to operate the AED”. Several orientation meetings were also held for new hires, mid-career staff and staff taking childcare leave.
- Office of Infection Control and Prevention
・We conduct regular infection control seminars for all staff and provide comprehensive training for new employees. Additionally, we offer feedback to physicians to promote the appropriate use of antibiotics.
・The infection control nurses also provide consultation services on infection control measures to local hospitals and healthcare facilities.
・In 2024, we organized seminars covering following topics: “Antimicrobial Resistance”, “Antimicrobial Use in Outpatient Settings”, “COVID-19 Vaccines”, and” Antibiotic Allergies”.
Future prospects
- Office of Clinical Safety
We will work to raise the awareness of medical safety among employees by having them consider medical safety as their own issue through the Office of Clinical Safety rounds and training to promote and establish a culture of safety in the hospital. In the next period, we will further strengthen cooperation with risk managers, etc., and strive to prevent accidents, disseminate decisions, and evaluate the status of implementation.
- Office of Infection Control and Prevention
・We will secure medical education funding to take the initiative in promoting vaccination for cancer patients.
・It is anticipated that incidents of COVID-19 among hospitalized patients will persist in the future. Therefore, our goal is to prevent intra-hospital transmission through early detection and rapid response.
・In line with national policy for antimicrobial resistance, we will continue our efforts to promote the appropriate use of antibiotics.
・We are advancing the development of personnel responsible for infection control to strive towards creating a sustainable organization.