Measures to promote medical safety
In Kobe City Medical Center, as a central organization for accident prevention, the Medical Safety Management Council (renamed from the Risk Management Subcommittee in April 24) and Risk Management is installed. In addition, we have appointed a safety manager in charge of medical safety in each department.
The Risk Management is an organization under the direct control of the hospital director that implements medical safety management. We are working on ongoing medical safety activities. Specific tasks include grasping the actual situation of incidents and accidents, analyzing background factors, considering measures to prevent recurrence, instructing, enlightening, and publicizing improvement measures, etc., and planning staff training related to medical safety.
The Medical Safety Management Council plays a central role in the hospital's medical safety measures by reviewing items related to medical safety management, such as preventing medical accidents and improving the quality of medical care, including education, once a month. increase.
In addition, the Infection Prevention Committee (consideration of problems related to infection control and determination of policies), Pharmaceutical Affairs Committee (implementation of drug safety management), Medical Device Safety Management Committee (safety management and assurance of medical devices), and employee safety and health We are working in cooperation with the committee (prevention of occupational accidents, etc.) and the medical material review committee (deliberation on the adoption of new medical materials, etc.).
In addition, the efforts of the Risk Management so far are as follows.
Click each item for details
In FY2022, we continued to hold daily medical safety meetings, and monthly medical safety management meetings to discuss and analyze cases related to medical safety. Regarding accident cases and in-hospital alarm cases, the medical safety leader meeting informed the staff in charge and conducted case studies.
Regarding medical safety training, we postponed the implementation of Nursing Department STEPPS last year from the perspective of preventing the spread of new coronavirus infections. It was held regularly every year. In addition, RRS brush-up training was held online, and e-learning training was originally created by our staff (38 courses in total). We have worked to ensure that all staff members can smoothly take the course at least twice a year while working to strengthen it.
As an educational activity related to medical safety, we have been operating an in-hospital report check system since June 2019 with the aim of preventing oversight of radiological diagnosis reports, etc., and supporting expedited treatment planning. The Medical Safety Management Committee considers and implements countermeasures for problems that arise in daily operation, and also considers and implements manual revisions. We also worked to prevent and prevent medical accidents by creating and posting notices and posters to alert people in a timely manner.
With regard to efforts to manage medication, we have introduced a newly created internal medication management manual to each ward since FY2023. In the future, we will conduct checks and audits on usage status, analyze the number and content of incident reports related to medication, and revise the manual while working to ensure safer medication management.
In 2021, we continued to hold daily medical safety meetings, and monthly medical safety management meetings to discuss and analyze cases related to medical safety. Regarding accident cases and in-hospital alarm cases, the medical safety leader meeting informed the staff in charge and conducted case studies.
With regard to medical safety training, the team STEPPS, which was postponed last year from the perspective of preventing the spread of the new coronavirus infection, was implemented 14 times in total, mainly in the Nursing Department, after taking sufficient infection control measures. It was held regularly every year. In addition, RRS brush-up training was held online, and in the e-learning training, training (43 courses in total) created by our staff was implemented independently. We have worked to ensure that all staff members can smoothly take the course at least twice a year while working to strengthen it. As a result, we achieved a 100% participation rate (including cooperating companies).
As an educational activity related to medical safety, we have been operating an in-hospital report check system since June 2019 with the aim of preventing oversight of radiological diagnosis reports and supporting expedited treatment planning. Each time a problem arises, the Medical Safety Management Committee considers and implements countermeasures, and is also considering revising the manual.
Regarding efforts to prevent falls, we assess the risk of falls whenever there is a change in the patient's condition based on the fall prevention manual, and take preventive measures according to the risk. We explain to patients the need to prevent falls and ask for their cooperation. In addition, regarding movement restrictions, at our hospital, we select the minimum necessary method that minimizes the physical and mental burden on patients, and observe them as needed, so that movement restrictions can be lifted as soon as possible.
We also created a revised version of the pocket manual on medical safety and distributed it to each staff member so that it could be carried around. In addition, we strived to prevent and prevent medical accidents by regularly distributing notices to call attention.
In 2020, due to the impact of the new coronavirus infection, the annual group training was restricted, and we shifted to a training system that actively used e-learning. In addition to holding daily medical safety meetings, monthly medical safety management meetings were held to examine and analyze cases related to medical safety. Regarding accident cases and in-hospital alarm cases, the medical safety leader meeting informed the staff in charge and conducted case studies.
Regarding medical safety training, participatory training is desirable. Team STEPPS has postponed the implementation from the perspective of preventing the spread of new coronavirus infections, but after taking sufficient infection control, ICLS and BLS training will be held regularly as usual. held. In addition, RRS brush-up training was held online, and in the e-learning training, training (total of 28 courses) created by our hospital staff was implemented. We have worked to ensure that all staff members can smoothly take the course at least twice a year while working to strengthen it. As a result, we achieved a 100% participation rate (including cooperating companies).
As an educational activity related to medical safety, we have been operating an in-hospital report check system since June 2019 with the aim of preventing oversight of radiological diagnosis reports and supporting the speeding up of treatment planning. With the aim of improving this, we launched a new "WG for Imaging Finding Omission Countermeasures" to examine cases and discuss countermeasures to reduce incidents related to diagnostic imaging orders. The results of the deliberation were disseminated to hospital staff through medical safety managers meetings.
As part of our efforts to prevent patients from being mistaken, we changed the wristbands used by all patients, including newborns, to include their names and dates of birth. As a result, we are striving to prevent further patient mistakes by asking the patient to state their name and date of birth while visually checking the wristband.
Regarding efforts to prevent falls, we assess the risk of falls whenever there is a change in the patient's condition based on the fall prevention manual, and take preventive measures according to the risk. We explain to patients and their families the need to prevent falls and ask for their cooperation. In addition, regarding movement restrictions, at our hospital, we select the minimum necessary method that minimizes the physical and mental burden on patients, and observe them as needed, so that movement restrictions can be lifted as soon as possible.
We also created a revised version of the pocket manual on medical safety and distributed it to each staff member so that it could be carried around. In addition, we strived to prevent and prevent medical accidents by regularly distributing notices to call attention.
August 2021
In FY2019, we continued to hold daily medical safety meetings, and monthly medical safety management meetings to discuss and analyze medical safety cases. Regarding accident cases and in-hospital alarm cases, the medical safety leader meeting informed the staff in charge and conducted case studies.
Regarding medical safety training, we mainly held employee participation training such as team STEPPS, RRS brush-up training, and simulation training. (The number of training sessions held in 2019: 102 times) In addition, we continued e-learning this year and worked to ensure that all staff can attend medical safety training at least twice a year.
As an educational activity related to medical safety, in-hospital report checks have been started from June 3, 2019 with the aim of preventing oversight of radiological and pathological diagnosis reports, supporting expedited treatment planning, and improving medical safety. System operation has started. In addition, on March 2, 2020, we started operating a hepatitis check system with the aim of preventing viral hepatitis patients from being overlooked and leading to appropriate treatment and follow-up. Furthermore, based on incident cases, we revised the manual as needed and posted it on WEBMINK to disseminate it.
As part of our efforts to prevent patients from being mistaken, we have made it possible for all patients, including newborns, to use wristbands. We strive to prevent patient error.
Regarding efforts to prevent falls, we assess the risk of falls whenever there is a change in the patient's condition based on the fall prevention manual, and take preventive measures according to the risk. We explain to patients and their families the need to prevent falls and ask for their cooperation. In addition, regarding movement restrictions, at our hospital, we select the minimum necessary method that minimizes the physical and mental burden on patients, and observe them as needed, so that movement restrictions can be lifted as soon as possible.
We also created a revised version of the pocket manual on medical safety and distributed it to each staff member so that it could be carried around. In addition, we strived to prevent and prevent medical accidents by regularly distributing notices to call attention.
In the fiscal 2018 revision of medical fees, regarding medical safety measures, a new addition was added to evaluate collaborative efforts that transcend the framework of medical institutions. to improve the quality of medical safety.
September 2020
In FY2018, we continued to hold daily medical safety meetings, and monthly medical safety management meetings to discuss and analyze cases related to medical safety. In addition, we reviewed cases of accidents and in-hospital alarm cases and disseminated them to the people in charge at the Medical Safety Leaders Meeting. In addition, in October 2018, we changed the operation and revised various manuals due to the update of the electronic medical record.
Regarding medical safety training, we mainly held employee participation training such as team STEPPS, RRS brush-up training, and simulation training. (The number of training sessions held in FY2018: 102 times) In addition, we continued e-learning this year and worked to ensure that all staff can attend medical safety training at least twice a year.
As an educational activity on medical safety, one year after the change in the RRS activation criteria for hospital-onset cerebral infarction, we reported on the results within the hospital. In addition, based on incident cases, we revised the manual as needed and posted it on WEBMINK to disseminate it.
As part of our efforts to prevent patients from being mistaken, we not only use name bands and check patient names on patient registration cards, but also work to prevent patient mistakes by having the patients themselves cooperate with us.
Regarding efforts to prevent falls, we assess the risk of falls whenever there is a change in the patient's condition based on the fall prevention manual, and take preventive measures according to the risk. We explain to patients and their families the need to prevent falls and ask for their cooperation. In addition, regarding movement restrictions, at our hospital, we select the minimum necessary method that minimizes the physical and mental burden on patients, and observe them as needed, so that movement restrictions can be lifted as soon as possible.
We also created a revised version of the pocket manual on medical safety and distributed it to each staff member so that it could be carried around. In addition, we strived to prevent and prevent medical accidents by regularly distributing notices to call attention.
In the 2018 medical fee revision, in response to the addition of a new addition to evaluate efforts in collaboration beyond the framework of medical institutions (medical safety measures regional collaboration addition) for medical safety measures, other medical services related to medical safety measures We shared cases and information with institutions and conducted mutual evaluations to further improve the quality of medical safety.
July 2019
In fiscal 2017, we continued to hold daily medical safety meetings, and held monthly medical safety management meetings to discuss and analyze cases related to medical safety. Regarding accident cases and in-hospital alarm cases, the medical safety leader meeting informed the staff in charge and conducted case studies. In addition, in November, the Advanced Medical Center Hospital was integrated and started operating as the South Building of the Kobe City Medical Center. established a medical safety system.
Regarding medical safety training, we introduced e-learning this year as well, focusing on team STEPPS, RRS brush-up training, and simulation training, and worked to ensure that all staff could attend medical safety training at least twice a year.
As an educational activity related to medical safety, we established RRS activation criteria and an operation manual for in-hospital cerebral infarction, and conducted training and put up posters in the ward. In addition, based on incident cases, we revised the manual as needed and posted it on WEBMINK to disseminate it.
We also created a revised version of the pocket manual on medical safety and distributed it to each staff member so that it could be carried around. In addition, we strived to prevent and prevent medical accidents by regularly distributing notices to call attention.
July 2018
In fiscal 2016, we continued to hold daily medical safety meetings, and held monthly medical safety management meetings to discuss and analyze cases related to medical safety. In addition, we held a medical safety leader meeting every month to familiarize the people in charge with preventive measures. For example, we thoroughly evaluated the prevention of DVT (deep vein thrombosis) and prepared a duty manual for each department.
In addition, from this fiscal year, we have introduced e-learning-based medical safety training, and have introduced a system that allows all staff to study at their own convenience using the Internet from their home computers. By simulating cases that are useful not only for doctor and nurses, but also for other occupations, we have incorporated them so that they can acquire a wide range of knowledge about medical safety.
As educational activities related to medical safety, we hold medical safety workshops ("medical gas workshops, MR examination workshops, insulin therapy workshops, glass batch workshops, NCM lectures, RST study sessions, risk management of imaging examinations, team STEPPS, medical mediator training), In the practical training (cardiopulmonary resuscitation training, central venous catheter insertion training, thoracic drainage training, ventilator safety management, safe handling of blood transfusions, lifesaving emergency training, emergency response training) has been held.
We also created a revised version of the pocket manual on medical safety and distributed it to each staff member so that it could be carried around. In addition, we strived to prevent and prevent medical accidents by regularly distributing notices to call attention.
June 2017
In fiscal 2015, we continued to hold daily medical safety meetings, and held monthly medical safety management meetings to discuss and analyze cases related to medical safety. In addition, we held a medical safety leader meeting every month to familiarize the people in charge with preventive measures. For example, we have implemented new measures such as thoroughly disseminating information on how to use new materials, and setting training targets for chest drains and requiring them to attend.
In addition, regarding the "Medical Adverse Event Investigation System," which came into effect in October, we have made staff aware of the outline of this system, and have created the "Guidelines for Medical Adverse Event Investigation" and the "Manual for Response to the Medical Adverse Event Investigation System." For all death cases that occurred in the hospital, we have established a check system to quickly determine the appropriateness of the relevant case based on the death case report. As a result, we have established an operation that can smoothly respond to cases that fall under this system.
As educational activities related to medical safety, we hold medical safety workshops ("Medical gas training") with the aim of improving the safety awareness of individual staff members and improving the medical safety of the hospital as a whole by disseminating and thoroughly understanding specific methods for preventing accidents. ``MR examination workshop'' ``insulin therapy workshop'' ``glass batch workshop'' ``blood transfusion workshop'' ``NCM lecture'' ``RST study session'' ``Medical Adverse Event Investigation System'' ``Team STEPPS'') and practical training ("cardiopulmonary resuscitation course", "central venous catheter insertion training", "thoracic drain insertion training", "emergency emergency training", "emergency response training"). learning learning As a result, all employees are now able to receive at least two medical safety courses.
We also created a revised version of the pocket manual on medical safety and distributed it to each staff member so that it could be carried around. In addition, we strived to prevent and prevent medical accidents by regularly distributing notices to call attention.
June 2016
Patient-Healthcare Professional Partnership
In order for patients to receive high-quality medical care safely and comfortably, it is necessary to build a better relationship of trust between patients and medical professionals and work together (partnership). Therefore, Kobe City Medical Center General Hospital has established the following activity policy.
1. We will support patients so that they can make appropriate self-determination of medical policies.
- The attending physician strives to explain the diagnosis, examination, and treatment of the disease, including surgery, in a polite and easy-to-understand manner as much as possible, and supports the patient in making their own medical decisions. If you have any questions or concerns, please do not hesitate to ask them.
- If you would like to hear the opinions of other hospitals/ doctor (second opinions), please do not hesitate to ask.
- You can request medical record disclosure to know the medical care you are receiving. Feel free to request it. (Contact: Medical Affairs Division)
2. We ask for the cooperation of patients and their families for safety management.
- In order to prevent mistaken identity, we ask for your name at various places such as inspection and reception. Please answer with your full name.
- Please tell your doctor or nurse as accurately as possible medical information such as your medical history, medical history, allergy history, etc.
- Please let us know at any time if you feel uneasy during treatment.
- Be sure to tell your doctor or nurse about any medicines prescribed at other hospitals or over-the-counter medicines you are taking, along with your medication information, medicine notebook, and medicine instructions.
3. We strive to provide appropriate medical information and respond to medical consultations.
- We hold health lectures and disease lectures for patients and citizens. For details, please ask in the General Information.
- We also provide consultation on social issues faced by patients and their families, social rehabilitation, medical expenses, admission to facilities, nursing care consultation, medical accidents, etc. (Counter: Patient Support Center)
4. Other requests
- Please follow the hospital rules and listen carefully to the staff's explanations so as not to interfere with the medical care of other patients.
- If you have any complaints or suggestions regarding medical services in general, please use the opinion box installed in the hospital. We will respond directly to your comments or post them on the bulletin board at the entrance of the 2nd floor.
