Annual Report 2020

Department of Safety Management, Office of Clinical Safety

Masaru Konishi, Kiyotaka Yoh, Masami Muto, Masato Yonemura, Shinya Motonaga, Yoko Uda, Ayako Hamanaka and Natsuko Okamoto

Introduction

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

The Team and What We Do

 Since 2016, two full-time staff members (a pharmacist and a nurse) have worked at the Office of Clinical Safety to strengthen organization. We have started a committee to introduce new high-level medical technology to enable our designation as an advanced treatment hospital. Routine office activities include the examination and analysis of all incident cases in hospitals. The criteria for incident reports on adverse events were revised. We also establish counterplans for serious cases and make them well known to all the staff. Staff doctors also conduct medical record surveys of all in-hospital death cases, and preside over mortality and morbidity conferences. A rapid response system was initiated to support emergency care. A prompt in-hospital case study meeting was held for one case in order to respond to medical accident investigation systems, and an in-hospital medical accident investigation committee meeting was held for one case. However, there were no cases judged as necessary to report to the Japan Medical Safety Research Organization.

Research activities

 The total number of incident reports was 6135; 676 cases (11%) from doctors, 4659 cases (76%) from nurses, 342 cases (6%) from pharmacists, 118 cases (2%) from radiological technicians, 95 cases (1%) from laboratory technicians, 60 cases (1%) from nutritionists, 63 cases (1%) from clerical staff, 49 cases (1%) from CRC, 73 cases (1%) from others. There was one report to the Japan Medical Safety Research Organization. Three safety reports for medical devices were made to the PMDA in two cases.

Education

 This year, there were two lectures on safety management in the NCCHE. One was on the Medical Accident Investigation System and the other was on the organization of safety management and experience in the NCCHE. Several orientation meetings were held for new hires, MD career staff and staff on childcare leave.

Future Prospects

 This year, we have strengthened the safety management organization, and the number of reported incidents has increased. We have improved the medical safety awareness of all the staff. The future goals including for next year are zero patient misidentifications and a 12% rate of incident reporting from doctors.