Annual Report 2018

Department of Safety Managment, Office of Clinical Safety

Masaru Konishi, Kiyotaka Yoh, Masami Muto, Takahiro Nishimura, Masahito Yonemura, Kaori Horiuchi

Introduction

 The Office of Clinical Safety has been established as the department responsible for cross-organizational safety management in our hospital in order to practice best medical service and care for cancer patients.

The Team and What We Do

 Since 2016, two full-time staff (a pharmacist and a nurse) worked at the Office of Safety Management to strengthen organization. And we have started a committee to introduce new high-level medical technology in order to permit designation as an advanced treatment hospital. Routine activities of the office are the examination and analysis of all incident cases in hospitals. We also establish counterplans for serious cases and make them well known to all staff. Also, staff doctors perform medical record surveys of all in-hospital death cases, and chair mortality and morbidity conferences. Four prompt case study conferences were held in hospitals in order to correspond to medical accident investigation systems; however there were no cases judged as necessary to report.

Research activities

 The total number of incident reports was 5,547 cases; from doctors: 508 cases (9%), from nurses 4,433 cases (80%), from pharmacists: 252 cases (5%), from radiological technicians: 117 cases (2%), from laboratory technicians: 68 cases (1%), from nutritionists: 31 cases (<1%), from clerical staff: 10 cases (<1%), from CRC: 36 cases (<1%), and from others: 76 cases (1%). There were two safety reports for medical devices to PMDA was reported. There were three in-hospital case study meetings and one in-hospital accident investigation committee meeting, but no reports were made to the Japan Medical Safety Research Organization.

Education

 This year, there were two lectures about safety management in the NCCHE. One was the management of severe acute respiratory failures and the other was the organization of safety management and experience in the NCCHE. Also, some orientations were held for new hires, mid-career staff and staff taking childcare leave.

Future prospects

 This year, we strengthened safety management organization, and the number of incidents reported increased. We could improve the medical safety awareness of all the staff. The future goal is zero patient misidentifications, 12% of incident reporting from doctors.