Annual Report 2021
Department of Safety Management, Clinical Safety Management Office
Masaru Konishi, Kiyotaka Yoh, Masami Muto, Masato Yonemura, Shinya Motonaga, Ayako Hamanaka, Natsuko Okamoto
Introduction
The Office of Safety Management has been established as the department responsible for the cross-organizational safety management in our hospital in order to practice the 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) have worked at the Office of Safety Management to strengthen organization. We have also 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. The criteria for incident reports on adverse events were revised. 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. A rapid response system was initiated to support emergency care. A prompt in-hospital case study meeting was held for two cases in order to respond to the Medical Accident Investigation System.
Research activities
The total number of incident reports was 6065 cases; from doctors: 731 cases (12%), from nurses 4504 cases (74%), from pharmacists: 301 cases (5%), from radiological technicians: 154 cases (3%), from laboratory technicians: 85 cases (2%), from nutritionists: 78 cases (1%), from clerical staff: 67 cases (1%), from CRC: 61 cases (1%), from others: 84 cases (1%). The fall rate of inpatients was 0.251%, and 16.3% of them were due to nurse-related factors. Three safety reports for medical devices were taken to the PMDA.
Education
This year, there were two lectures about safety management in the NCCHE. One was about the Medical Accident Investigation System and the other was about the patient misidentifications in the hospital. Also, some orientations were held for new hires, mid-career staff and staff taking childcare leave.
Future Prospects
This year, we strengthened the safety management organization, and the number of incidents reported increased. We could improve the medical safety awareness of all the staff. The future goals including for next year are zero patient misidentifications and a 13% rate of incident reporting from doctors.