The Implementation of Adverse Events Reporting System and Sharing Experiences among Acute Hospitals

本项目的目标是实施不良事件报告系统，并共享短期急性医院的信息，以防止医疗护理中的错误。已鼓励日本优质医疗保健理事会（JCQHC）认证的医院提供每家医院发生的不良事件信息，以讨论哨兵事件，预防复发。已经组织和管理了7次会议，例如，关于用药过程、管道故障、医疗设备、计算机化系统等，以分析病例并审查预防措施。这3年来，已经发布了几项关于患者安全的建议、警报和指南。防止高风险药物（即KCl和局部麻醉药物）过量的紧急建议对日本医院产生了强烈影响。中心静脉置管指南对预防非预期并发症和MRSA感染是有效的。这些产品通过研讨会、论坛和季刊分享，以确保患者安全。医院之间。参加会议的医院迅速增加，目前已达890家。项目结束后，将在JCQHC继续开展患者安全性促进活动。

The objective of this project is to implement the adverse events reporting system and sharing information from short term acute hospitals to prevent errors in medical care. Hospitals accredited by Japan Council for Quality Health Care (JCQHC) have been encouraged to offer information on adverse events experienced in each hospital to discuss sentinel events among themselves for recurrence prevention. 7 conferences, for example, on medication process, tube troubles, medical equipments, computerized systems, etc.have been organized and managed to analyze the cases and review preventive measures. These 3 years, several proposals, alerts and guidelines have been issued for patient safety. An urgent proposal to prevent overdose of high-risk drugs i.e. KCl and the local anesthesia drugs, had strong influences on Japanese hospitals. The guideline for the central venous catheterization was effective to prevent unexpected complications and MRSA infection. These products have bean shared through seminars, forums and quarterly journals for patient safety. Among hospitals. The number of hospitals to take part in these conferences has increased rapidly and reached 890 at present. This activity for patient safety promotion is to continue in JCQHC after the project.