Department of Safety Management

Masaaki Ito, Kiyotaka Yoh, Naoto Gotohda, Keiji Okinaka, Wakana Kitazawa, Asako Hashimoto, Hiromi Fujita, Masahito Yonemura, Shinya Motonaga, Ryuko Shimoda, Satoshi Saito, Akira Shinohara, Kenya Tanimoto, Go Sato, Keisei Nakamura, Raika Miyahira

Introduction

• Office of Clinical Safety

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

• Office of Infection Control and Prevention

The Office of Infection Control and Prevention was established in October 2016. The objective of our office is to promote hospital infection control to reduce the transmission of communicable diseases among patients, healthcare workers, and visitors. Our office also promotes antimicrobial stewardship.

Routine activities

• Office of Clinical Safety

Since 2016, two full-time staff members (a pharmacist and a nurse) have been working in the safety management office to strengthen the organization. And 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 hospitals. The criteria for reporting adverse events have been revised. In addition, contingency plans for serious incidents are established and communicated to all staff. In addition, 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.

• Office of Infection Control and Prevention

Our missions include:

- Developing infection control policies and in-hospital guidelines

- Managing the surveillance system of healthcare-associated infections and drug-resistant bacteria to prevent outbreaks of infectious diseases

- Maintaining manuals regarding infection control and antimicrobial stewardship

- Inspecting and improving the quality of the hospital environment using ward rounds

- Inspecting and improving compliance with hand hygiene and other infection control measures using ward rounds

- Offering consulting services regarding infection control problems

- Preventing and managing needlestick injuries

- Vaccinating staff with insufficient protective immunity

- Planning the provision of employee education and educational campaigns to promote infection control and antimicrobial stewardship

- Planning conferences among regional hospitals to promote the improvement of infection control in each hospital

- Promoting antimicrobial stewardship

- Inspecting and promoting the proper disposal of medical waste

・In 2023, our activities focused on improving hand hygiene compliance rates, preventing the spread of COVID-19, addressing facility-related concerns such as Legionella in tap water, and preparing for evaluation by the Japan Council for Quality Health Care.

Research activities

• Office of Clinical Safety

Total number of incident report was 5867 cases; from doctors: 578 cases (10%), from nurses 4526 cases (77%), from pharmacists: 235 cases (4%), from radiological technicians: 163 cases (3%), from laboratory technicians: 151 cases (3%), from nutritionists: 57 cases (1%), from clerical staff: 19 cases (<1%), from CRC: 14 cases (<1%), from others: 143 cases (2%). The fall rate of inpatients was 0.234%, and 19.2% of them were due to nurse’s factors. No medical device safety reports were submitted to the PMDA during this period.

• Office of Infection Control and Prevention

・We hold weekly interdisciplinary research meetings to support ongoing and emerging studies. Recent research initiatives include:

・Evaluating risk factors for false positives in HIV screening tests

・Analyzing trends in COVID-19 antiviral prescriptions

・Assessing the efficacy of rapid microbial identification devices

・We have also initiated activities to promote vaccination for cancer patients and will continue conducting questionnaire surveys to evaluate the impact of these efforts.

Education

• Office of Clinical Safety

Training course of Team Strategies and Tools to Enhance Performance and Patient Safety (STEPPS), Training course of basic life support (BLS) and advanced cardiovascular life support (ACLS)

• Office of Infection Control and Prevention

・We conduct regular infection control seminars for all staff and provide comprehensive training for new employees. Additionally, we offer feedback to physicians to promote the appropriate use of antibiotics.

・The infection control nurses also provide consultation services on infection control measures to local hospitals and healthcare facilities.

・In 2023, we organized seminars covering topics such as blood and body fluid exposure, COVID-19 in cancer patients, vaccination, and the use of oral antibiotics.

Future prospects

• Office of Clinical Safety

We will work to raise the awareness of medical safety among employees by having them consider medical safety as their own issue through the Medical Safety Management Office 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.

• Office of Infection Control and Prevention

・We secure medical education funding in order to take the initiative in promoting vaccination for cancer patients.

・It is anticipated that incidents of COVID-19 among hospitalized patients will persist in the future. Therefore, our goal is to prevent intra-hospital transmission through early detection and rapid response.

・In line with national policy for antimicrobial resistance, we will continue our efforts to promote the appropriate use of antibiotics.

・We are advancing the development of personnel responsible for infection control to strive towards creating a sustainable organization.