Abstract
The TOYOTA-KAI Medical Corporation KARIYA TOYOTA General Hospital introduced the Order Entry System in 2003. A test tube preparation system, to manage blood collection tubes, was also established in the same year. The new system has enabled hospital staff to manage orders for lab tests systematically during working hours, but not during other times of the day. Appropriate measures should be taken to correct this.
Approximately two incidents per month have been reported, including failure to perform ordered tests and failure to cancel unnecessary tests because of poor communication regarding changes in orders. In addition, approximately one incident of patient misidentification has been reported per year, which could have resulted in a fatal outcome.In order to address these problems, the hospital has started a project to introduce a patient identification system for blood sample collection. This project is mainly being carried out by the Safety Management Team (SMT) and the SMT Working Unit, which is an SMT's subordinate unit including nurses, co-medical staff, and clerical staff. Unit members are addressing medical safety issues through a cross-functional approach.
When the Order Entry System was established, the hospital also sought the opinions of nurses, co-medical staff and clerical staff for a more multilateral perspective. On the basis of those opinions and a shell-model analysis, problems were identified and system goals clarified. Through these efforts, a system has been established that takes into account medical safety and efficient job performance. Moreover, as a side benefit the accidents' incidences have decreased and the blood-collection process is now managed more effectively.
