Patient safety culture plays an important role in securing patient safety at hospitals. We investigated the applicability of the Japanese version of the Hospital Survey on Patient Safety Culture (HSOPS) developed by the US Agency of Healthcare Research and Quality, and compared results of surveys in the United States and Japan. The HSOPS includes 12 domains (42 questions) on patient safety culture and 2 questions regarding the overall evaluation of patient safety culture at a hospital.

9,867 healthcare staff of 13 acute care hospitals participated in this survey. Effective responses were received from 6,399 respondents (64.9%).

The proportions of respondents who affirmatively evaluated patient safety culture were different among professions, number of hospital beds and hospitals. “Teamwork within department” (70.3%) and “Frequency of the event report” (68.1%) were among the most highly evaluated domains. Physicians and nurses evaluated patient safety culture more affirmatively than office staff. The overall evaluation showed a high correlation with 5 domains (correlation coefficient 0.8 or more) and relatively high correlation with 4 domains (correlation coefficient 0.6-0.8).

The domains were classified into (1) high evaluation in most hospitals with low coefficient of variation (CV), (2) low evaluation in most hospitals with high CV, and (3) low evaluation in most hospitals with low CV.

In comparison Japanese healthcare workers evaluated patient safety culture lower than US healthcare workers.

The results of this study suggest that the Japanese HSOPS can be introduced in Japanese acute care hospitals, and can be used as a tool to measure patient safety.

The occurrence rate of the incident and/or accident reports related to operations was evaluated as a clinical indicator (CI) of operation-related issues. 6 major categories with 23 item classification model were designed to review the reports. During the period from April 2009 and March 2010, 62 incidents in 56 cases were reported and examined among 4,034 operations. 18 cases of unexpected reoperation, 15 cases of prolonged operation by 1.5 times of scheduled time, 4 cases of unmatched counts of gauze at the end of operation, 3 cases of higher amount of blood loss than expected, and 3 cases of broken surgical instruments were reported. The occurrence rates were 0.45%, 0.37%, 0.10%, 0.07%, 0.07%, respectively. Classification of incidents by operating departments were：surgery-12(cases) (occurrence rate calculated by the operation number performed by the individual department：12/696；1.72%), nursing division-11 (11/4,034；0.27%), orthopedics-10 (10/442；2.26%), thoracic surgery-10 (10/122；8.20%), anesthesiology-5 (5/1,801；0.28%), otolaryngology-5 (5/330；1.52%), urology-4 (4/420；0.95%), cardiology-2 (2/55；3.64%). We suggest that an annual review of CI is effective in evaluating the improvement of the medical environment. The official announcement of CI would also make it possible to compare hospital evaluation and promote transparency of medicine, resulting in achieving patients' consent. We concluded that the induction of occurrence rates of operation-related incidents and/or accidents to CI would improve safety management, quality of medical care, and foremost, contribute to the prevention of the medical accidents.

Critical pathways on paper-based medical charts for AMI patients were designed, and are presently in use in many hospitals. However, it is difficult to run under an electronic medical chart system because of its inflexibility. We recently designed 4 different critical pathways and applied them to AMI patients on an electronic medical chart system. The patients' conditions after emergency percutaneous coronary intervention (PCI) were classified into 2 groups：severe case and mild case. Moreover, progression of bed rest level, periodical blood sampling time and other post-PCI treatments, depend on the termination time of PCI. Therefore, we added a separate category according to termination time of PCI；one as the morning group (PCI ending from 0:00am to 12:00am） and the other as evening group (PCI ending from 0:00pm to 12:00pm). Under this definition, four different critical pathways：1) mild case morning group, 2) mild case evening group, 3)severe case morning group, and 4)severe case evening group, were defined. The appropriate critical pathway is selected from 4 critical pathways followed by the post-PCI patient condition and the termination time of PCI. A critical pathway in the mild case group consists of 4 different periods：the acute period, the recovery period, the rehabilitation period, and the discharge period. In the severe case group, 7 different periods are set. Physician starting the critical pathway after the end of PCI and has to choose additional treatment such as：periodical blood sampling, IABP use, oxygen use and others during the initiation of the acute period.

These critical pathways have already been applied to 29 patients, and reflect the actual clinical course of most of those cases.

The Diabetes Center of the Tokyo Women's Medical University (TWMU) was founded in 1975 and its mission is to treat diabetes in an interdisciplinary manner. To achieve its goal, regional medical cooperation was placed among its highest priorities. As an acute care hospital and a high quality university hospital, referrals from local clinics and hospitals are welcomed but when the referred patients remain with the outpatient department of the TWMU Diabetes Center no vacancies for new referrals open up. To be able to continue receiving new cases reversed referrals have become necessary.

This study describes the aggressive method that was introduced to enhance regional medical cooperation and compares referral and reversed referral rates between the Diabetes Center and the TWMU hospital as a whole over the period from 1995 to 2008. The result shows that both, referral and reversed referral rates were significantly higher in the Diabetes Center throughout the period.

According to the result of a questionnaire put to the physicians at the Diabetes Center, most doctors were well aware of the importance of regional medical cooperation. When they were asked for suggestions regarding a strategy to increase the numbers of both referrals and reversed referrals, the most frequent answer was to hold a regional medical liaison conference with referring doctors and publishing the results of such a conference in the Diabetes Center's newsletter. Also, the introduction of an improved referral letter form was recommended. On the question of how to increase reversed referrals the importance of patients' (family) education, the completion of an accurate database of referring doctors and the thorough explanation to the patient to return to the original physician when the condition stabilizes was pointed out. The utilization rate of the current database was quite high with 93%, but there were voices to further improve the database.

It has been found that follow-up procedures for letters of introduction from other hospitals to the Kurobe City Hospital are not satisfactory. To correct this discontent, starting January 4, 2010 the hospital began drafting example letters of introduction and responses into its medical support system called Yahgee. This system is a document-making tool, which additionally serves as a database. Simultaneously, the hospital also began generating Yahgee documents providing information about letters of introduction from other hospitals.

A classification was introduced to each document, differentiating between a first report, an interim report and a final report. This enables a check whether a final report had been written or not. Additionally the inter-regional association room was released of the huge office work of inputting information about letters of introduction into the database.

It became also possible to officially publish a monthly report stating those cases, which haven't yet seen a final report. Before April 2010 the system was adjusted again including introduction information from other hospitals. Since then, it became possible to not only distinguish whether a final report had been written or not but also sort documents that do not need a further reply or those for which the final report will take a much longer time. Furthermore, each physician is now able to easily draw his own list from the database of cases, which haven't yet been finalized with a final report.

We carried out a questionnaire survey to investigate the actual conditions of discharge planning sections, discharge nurses, and discharge supervisors in the Tokyo metropolitan area.

Among responding hospitals, 84%, or 70 hospitals had a discharge planning section, 96% had Medical Social Workers (MSWs), 56% had discharge nurses, and 27% had administrative positions. The results show that the number of nurses placed in acute hospitals is increasing, and that in recent years, the need for discharge nurses, who can get involved in both, treatment and lifestyle assessments, has been projected to increase, especially in acute hospitals. Additionally, this study found that within the duties related to discharge plans, ‘Interviews for decision-making support’ between discharge nurses and MSWs are frequently carried out. More and more nurses are involved with treatment, while more MSWs are involved with an efficient utilization of the system and assisting with transfers. While MSWs are more likely to assist with transfers, discharge nurses are more likely to carry out home support. However, this study does not show statistically significant differences in data relating to home support. The authors believe that the reason is that discharge nurses and MSWs are directly cooperating with each other on that issue.

As a result of this study, we suggest the following three improvements for discharge nurses positions：1) introduction of discharge planning system：building a cooperation network to link the in-house system with multiple specialists outside the hospital in order to increase multiple in-house specialists；2) training of in-house staff；and 3) further development of the required skills of nurses assisting with discharging, including decision-making support skills.

The Nittazuka Medical Welfare Center is a medical complex consisting of 4 corporations, 11 facilities and one private company. As of June 2010, more than 1,100 employees work at the center in various types of jobs. This study examines all employees', except physicians' attendance of the third and fifth year mandatory training courses based on their assignments after each training course.

In the third year training course, participants focus on reviewing their positions by interacting with people in other jobs. In the fifth year training course, participants aim to determine how their skills contribute to the center.

This study covered the same 46 participants from the third year training of 2007 and the fifth year training of 2009.

The word extraction method was used to pick the following 8 keywords from the assignments conducted after each training：training themes, training methods, individuals, coworkers, job categories and departments, facilities and the center, management and human resource development.

The usage rate of “training themes” accounted for 71.7% of the assignments for the third year training and 91.3% of the assignments for the fifth year training. The usage rates of the keywords：“job categories and departments,” “facilities and the center,” and “management” also increased from the third year training to the fifth year training, while in comparison, “coworkers” and “human resource development” decreased.

In view of the results for each individual participant, third year training participants used an average of 4.41 keywords in their assignments and fifth year training participants an average of 5.46 keywords respectively. This result shows that after 2 further years of work and training experience each employee views things from a broader perspective.

However, the rate of the use of the keyword：“management” remained at a 30% level on the assignments. It seems that further in-service training is necessary to increase the employees' awareness towards management responsibilities and human resource development.