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

该项目的目的是实施短期急症医院不良事件报告系统和信息共享，以防止医疗差错。已鼓励日本优质保健委员会（JCQHC）认可的医院提供关于每家医院所经历的不良事件的信息，以便讨论它们之间的前哨事件，以预防复发。组织管理了用药过程、管材故障、医疗设备、计算机化系统等7场会议，分析案例，回顾预防措施。这三年来，针对患者安全发布了若干建议、警报和指南。紧急提出防止KCl和局部麻醉药物等高危药物过量使用的建议对日本医院产生了强烈的影响。中心静脉置管指南可有效预防意外并发症和MRSA感染。这些产品通过研讨会、论坛和患者安全季刊进行分享。在医院。参加这些会议的医院数量迅速增加，目前已达到890家。这项促进患者安全的活动将在项目结束后继续在JCQHC进行。

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.