Medical Safety Management System
1. Basic View on Medical Safety Management
Medical safety is an important subject associated with quality of medical care. It is a basis of medical care to provide safe medical care. It is most important that each department and individual staff member recognize necessity and importance of medical safety as a subject of their own department and individual, establish medical safety management system, and consistently pursue safe medical care. For this purpose, the Medical Care Safety Management Department is established, and the Medical Care Safety Management Committee and Anti-Infection Committee are set up to establish medical care safety management. Based on analysis and evaluation of incidental cases and medical accidents, manuals and the like are revised to reinforce and upgrade the medical care safety management.
2. Organization associated with Medical Care Safety Management
As an organization, to pursue this basic guideline, the Medical Care Safety Management Department was established. The Medical Care Safety Management Department consists of Anti-Infection Section, Clinical Engineering Section, Medical Care Safety Measure Section, and a Person in Charge of Drug Safety Management to assume safety management across organizations. In addition, based on medical care safety management, President of Hospital establishes the following committees to ensure safety management system regarding medical care:
- (1)Medical Care Safety Management Committee
To supervise the whole system regarding medical care safety management
- (2)Medical Care Safety Manager Meeting
To discuss countermeasures against incidents upon medical accidents
- (3)Safety Manager Meeting
To grasp incidental cases, consider improvement schemes, and to ensure publicity thereof in the hospital
3. Staff Training for Medical Care Safety Management
Regarding basic view and specific measures for safety management regarding medical care, training is given to the staff in consideration of the following:
- (1)Contents shall be regarding safety management common to the entire medical institution.
- (2)Training shall be held so that the staff can participate twice a year.
4. Improvement Scheme to Ensure Safety regarding Medical Care based on Reports, etc.
- (1)To maintain a report system utilizing an incident reporting system
- (2)To collect necessary information regarding incidental cases, to conduct factor analysis, and to share safety measures and recurrence prevention measures
- (3)To add necessary improvement measures to “Medical Care Safety Management Manual”
5. Actions upon Medical Accidents
- (1)Urgently call members concerned, and promptly conduct the best treatment to the patient.
- (2)Accurately record the development of events chronologically in a medical record, a care record, etc.
- (3)As long as there are no obstacles to save life after an accident, explain status of the accident, on-going recovery treatment, prospect thereof to the patient and his or her family as quickly as possible. If there is anything unclear at the time of explanation, explain that. Keep a record of the content of explanation.
- (4)As necessary, President of Hospital calls Medical Care Safety Manager Meeting.
6. Establishment of Patient Consultation Contact
- (1)Patient Consultation Contact is established in the hospital to respond to complaints and consultation from patients and others.
- (2)Complaints and consultations regarding medical care safety shall be reported to Medical Care Safety Measure Section to respond.
7. Basic Policy regarding Information Sharing between Health Professionals and Patients
- (1)Medical information regarding the patients' health shall be disclosed with the exception of special cases (in the case that the patient refuses being informed of cancer, or the family requests for considerable reasons).
- (2)This policy shall be indicated on the Web site and be disclosed to patients and their families upon request.
- (3)All disclosures shall comply with the Personal Information Protection Rules, and the information shall be disclosed according to the Medical Information Disclosure Procedures.
Revised on August 12, 2014
President of Hospital