Greetings
Medical Audit Division, an organization directly under the hospital director, consists of approximately 30 staff members, including doctors, nurses, pharmacists, technical staff, and administrative staff. It oversees medical safety, hospital infection control, and radiation therapy quality control throughout the hospital, and strives to improve the quality of medical care by raising awareness of crisis management across the organization and encouraging all medical professionals to improve their medical knowledge and skills and to communicate well with patients and their families. However, it is impossible to eliminate medical accidents entirely. To achieve this, we believe it is important for us to work as an organization every day to ensure the safety of medical care. To this end, we ask for the participation and cooperation of patients and their families so that we can provide high-quality medical care.
Medical Audit Division
Seiji Morita
Overview
Medical Safety
Medical safety measures have made great progress over the past decade. Since the publication of the Institute of Medicine's report "To Err is Human" in 1999, it has become common knowledge that medical accidents occur frequently. As a result, it has become common for hospitals across the country to consider measures to prevent medical accidents based on individual cases, such as through incident/accident report submission systems.
Our hospital submits approximately 5,000 reports annually. This number is comparable to that of other universities. The number of submitted reports can be seen as an indicator of the facility's active medical safety activities. In the process of considering preventive measures for submitted reports, we often visit the site and hear specific details from relevant staff. This is because medical care has become increasingly specialized and complex, and many aspects are difficult for those outside the field to immediately understand. Conversely, it is common for staff to be familiar with their own department but not the details of other departments. Holding cross-organizational meetings with staff from multiple departments helps us accurately understand the background and current situation of each incident. While accurately understanding the current situation is a daunting task, we believe it is one we must persevere in.
Furthermore, quality assurance (QA) and quality control (QC) are important in quality management of radiation therapy, so we maintain radiation irradiation techniques and identify potential and systematic errors.
Even with these medical safety activities, medical accidents cannot be reduced to zero. When an adverse incident occurs, the hospital's "Case Investigation Committee" conducts a detailed investigation of the facts, including with the participation of third parties other than the parties involved.
Infection-related
Hospital infection control is extremely important for providing safe, high-quality patient care. The core of our activities is timely problem recognition, surveillance to ensure appropriate infection control measures are implemented, and consultations focused on providing guidance on appropriate infection control measures. To plan hospital infection control, we have established a committee to determine prevention measures based on an understanding of the current state of hospital infections. Furthermore, under the Infection Control Office, the Infection Control Team (ICT), a multidisciplinary team (physicians, nurses, pharmacists, clinical laboratory technicians, and administrative staff) from each department, and the Antimicrobial Stewardship Team (AST), which supports the appropriate use of antimicrobials, regularly respond to specific cases through ward rounds and conferences.
The Infection Control Office, which is the base for ICT and AST activities, plans specific infection prevention measures and identifies issues early by assessing infection risks throughout the hospital, preventing outbreaks before they occur. In the event of multiple outbreaks, the infection route is identified and the spread is prevented.
AST understands the status of antibiotic use both inside and outside the hospital and works to promote the appropriate use of antibiotics. Through monitoring and conferences on cases of antibiotic use that require notification, cases of long-term antibiotic use, and positive blood cultures within the hospital, we provide specific feedback on appropriate use.
As a regional core hospital, our facility is responsible for coordinating with nearby medical facilities and has built a regional network for infection control. Our Infection Control Office is ready to answer any inquiries you may have.