Safety Management System
1 Organization for safety management in medical care
The safety management system is supervised by the Director-General. A full-time risk manager in charge of safety is appointed, various meetings are held, and safety management measures, etc., are carried out.
Also, the following basic items are set out as policies for medical-related safety management. These are posted in the front lobby of the hospital to inform the patients, etc., and included in the medical care staff manual to inform the staff members.
- Basic ideas of safety management
- Basic items on safety management committee and other organizations
- Basic policies regarding the staff training for safety management
- Basic policies on improvement measures for the purpose of ensuring medical safety, including accident reporting
- Basic policies on the actions to be taken in the occurrence of medical accidents, etc.
- Basic policies on the sharing of information between staff and patients, and the access of patients, etc., to the policies
- Basic policies regarding the response to consultation initiated by the patients
- Other basic policies necessary for the promotion of medical safety
2 Incident reporting system
The information relating to incidents that occurred in the hospital are collected by means of an online incident report system. In addition, the information is shared between the safety management office and individual risk managers to enable prompt analysis and actions to be taken for the incidents. In case of critical incidents, a more detailed report of the circumstances is required, and analysis is conducted on the causes and contributing factors to investigate specific measures to prevent a recurrence of the incident.
3 Preparation of medical accident prevention manuals
We prepare “medical accident prevention manuals” that not only include general precautions relating to safety, but also precautions that are specific to clinical departments and specific statuses (such as deep vein thrombosis). These manuals are stored at each clinical department, ward, and section. The key points that are considered especially important in this manual are compiled into a pocket version of the “medical staff manual.” These are revised every year and distributed to all staff members from fiscal 2001.
4 Training sessions for safety management in medical care
In order to heighten staff awareness regarding safety management in medical care, lecture sessions by lecturers inside and outside the hospital are held twice a year for all staff to attend. In addition, activity report meetings are held twice a year to present the incidents in wards, clinical departments, and sections. Also, case investigation meetings are held three times a year with doctors, nurses, co-medical staff, and administrative staff divided in groups to report the incidents that occurred.
5 Intensive month-long program for safety management in medical care
In addition to the key goals for safety management in medical care that we work on throughout the year, we also set out intensive month-long programs twice a year (June and November) to ensure that these key goals are met.
6 Awareness activities
The content of the risk manager meetings are reported to the staff by means of the “risk manager meeting report” and “risk management news.” In addition, we ensure that the information is communicated to individual staff via the risk managers of each section.