Annual Report 2024
Department of Safety Management, Office of Clinical Safety
Masahiko Kusumoto, Naoko Haji, Mei Sekine, Akiko Mizuta, Yoko Tamiya, Naoko Okada, Masato Ishida, Eisuke Kobayashi, Wataru Munakata, Toru Akagi, Makoto Maeda, Yoko Nakahama, Natsuko Okita
Introduction
The Office of Clinical Safety operates under our Safety Management Policy, placing patient safety first and promoting medical safety co-created with patients as our guiding principle. A balanced combination of “top-down” and “bottom-up” governance is essential to our clinical safety framework; in particular, reports from multiple professions form the foundation of bottom-up improvement. In FY2024, building on our evaluation of the prior year’s goals, we set five targets and advanced our clinical safety activities through repeated PDCA cycles.
The Team and What We Do
1. Activity Record
1. Committee for the Prevention of Medical Accidents and Related Events: 12 regular monthly meetings; 2 extraordinary meetings
2. Medical Safety Management Subcommittee: 12 regular monthly meetings
3. Risk Managers & Sub-Risk Managers Meeting: 12 regular monthly meetings
4. In-house Medical Accident Investigation Committee: 3 cases (number of first-session investigations convened)
2. Incident / Accident / Adverse Event Reporting
1. Number of reports: incident & accident reports, 5,999; Adverse event reports, 954
2. Reporter share by major profession: Physicians 20.7%; Nurses 64.6%; Radiological Technologists 4.0%; Registered Dietitians/Cooks 4.9%; Pharmacists 1.8%; Clinical Laboratory Technologists 2.2%; Physical Therapists / Others (ME, CRC, etc.) / Administrative staff 1.8%
3. Comprehensive Review of All Deaths
Conducted daily.
4. External Reporting
1. Reports to the Project to Collect Medical Near-Miss/Adverse Event Information by the Japan Council for Quality Health Care: 31
2. Reports to the Japan Medical Safety Research Organization (Medsafe Japan): 0 (number of cases registered as medical accidents)
Education and Training
1. Lectures on Medical Safety
1) Session 1: “Why Patient Engagement Matters” (attendance rate 100%)
2) Session 2: “Medical Safety and Patient and Public Involvement” (attendance rate 100%)
2. Cardiopulmonary Resuscitation training (10 sessions)
3. Orientation lectures for newly hired staff
4. Orientation for mid-career hires and returnees (11 sessions)
5. Medical Safety training lectures and drills for novice nurses (hosted by the Nursing Education Committee)
6. Level II Medical Safety Education and Training for Nurses (hosted by the Nursing Education Committee)
7. MRI magnetic-field safety experience training for physicians, nurses, and nursing assistants (4 sessions)
8. Study sessions on glycemic management for patients with cancer (2 sessions)
9. Medical gas safety management training (e-learning)
10. Procedures and observation for application of physical-restraint devices (2 sessions)
11. Medical safety training for contracted staff
Future Prospects
1. Based on our Phase III Medium- to Long-Term Plan goal of “enhancing the safety management framework,” we will set achievable goals that enable staff to advance clinical safety together and strive to build a self-regulating, self-improving medical safety culture.
2. We will continuously benchmark our internal status against external organizations and the latest guideline information using quantitative comparisons to sustain up-to-date, high-quality clinical safety management operations.
3. For root-cause analyses and recurrence-prevention planning related to deaths, adverse events, and incident/accident cases, we will ensure smooth responses through information sharing and joint analysis across the divisions of the Department of Safety Management (Office of Clinical Safety, Office of Infection Control and Prevention, Office of Patient Dialogue Promotion, Office of Advanced New Medical Technologies Management, and Office of Radiation Safety Management).
4. We will develop medical safety indicators appropriate for cancer specialty hospitals.
5. By staffing physicians, pharmacists, nurses, health information managers, and administrative personnel—thereby increasing the diversity of our dedicated clinical safety team—we will leverage each profession’s expertise to improve the quality of our clinical safety activities.