Annual Report 2022
Department of Safety Management, Office of Clinical Safety
Masaru Konishi, Yoichi Naito, Masami Muto, Hiromi Fujita, Masato Yonemura, Shinya Motonaga, Ayako Hamanaka, Miyuki Tango
Introduction
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.
The Team and What We Do
Since 2016, two full-time staff members (a pharmacist and a nurse) have been working in the clinical safety office to strengthen the organization. We have established a committee to introduce new high-level medical technology to enable designation as an advanced treatment hospital. The office's routine activities include the review and analysis of all incident cases in the hospital. The criteria for reporting adverse events have been revised. In addition, contingency plans for serious incidents are established and communicated to all staff members. Furthermore, 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.
Research Activities
The total number of incident reports was 6016; 641 cases (11%) from doctors, 4559 cases (76%) from nurses, 338 cases (6%) from pharmacists, 144 cases (2%) from radiological technicians, 97 cases (2%) from laboratory technicians, 54 cases (1%) from nutritionists, 27 cases (<1%) from clerical staff, 65 cases (1%) from CRC, 91 cases (2%) from others. The fall rate of inpatients was 0.246%, and 19.2% of them was due to nurse-related factors. No medical device safety reports were submitted to the PMDA during this period.
Education
During this period, there were two lectures about safety management in the NCCHE. One was about the Medical Safety Management System and Case Reports, and the other was about "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.
Future Prospects
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.