Annual Report 2019

Department of Safety Management, Office of Clinical Safety

Masaru Konishi, Kiyotaka Yoh, Masami Muto, Takahiro Nishimura, Shinya Motonaga, Yoko Uda, Sachiko Doi and 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. And we have started a committee to introduce new high-level medical technology in order to permit designation as an advanced treatment hospital. Routine activities of 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 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 was no cases judged as necessary to report to the Japan Medical Safety Research Organization.

Research activities

 Total number of incident report was 5826 cases; from doctors: 563 cases (9%), from nurses 4606 cases (82%), from pharmacists: 239 cases (5%), from radiological technicians: 141 cases (2%), from laboratory technicians: 84 cases (1%), from nutritionists: 64 cases (1%), from clerical staff: 25 cases (<1%), from CRC: 61 cases (1%), from others: 54 cases (<1%). There was one in-hospital case study meeting and one in-hospital medical accident investigation committee meeting, but no reports were made to the Japan Medical Safety Research Organization. Two safety reports for medical devices were made to the PMDA in two cases. High-level new medical technology evaluation committee meetings were held for two cases.

Education

 This year, there were two lectures about safety management in the NCCHE. One was about the idea of medical care and the other was about the organization of safety management and experience in the NCCHE. Also, some orientations were held for new hires, md-career staff and staff taking childcare leave.

Future prospects

 This year, we made strengthened 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 12% rate of incident reporting from doctors.