Although several maneuvers had been taken to encourage in-hospital patient safety management system, little is known about development of the system. We investigated the development of patient safety management system in hospitals by two questionnaire surveys.

A self-administered anonymous questionnaire was delivered to all member hospitals of the All Japan Hospital Association (2004：2,108 hospitals, 2011：2,290 hospitals). Hospitals were classified according to function and bed size；small acute care hospital with less than 300 acute care beds, big acute care hospital with equal to or more than 300 acute care beds, and long term care hospital.

Response rates were 24.0% in 2004 and 27.6% in 2011. From 2004 to 2011, full-time (more than 80 percent of working hours are spent for safety activities) safety managers increased at big acute care hospitals, and semi-full-time (50-79 percent of working hours are spent for safety activities) safety managers increased at small acute care hospitals and chronic care hospitals. In 2011, the proportion of hospitals with full-time/semi full-time safety managers was 46.1% at small acute care hospitals, 92.9% at big acute care hospitals and 24.5% at long term care hospitals. Activities relating to patient safety were improved by full-time safety managers in acute care hospitals and by semi-full-time managers in long term care hospitals. No improvement was observed in small acute care hospitals with semi-full-time safety managers.

It is necessary to consider and design support systems to promote the assignment of full-time/semi full-time safety managers at small acute care hospitals and long term care hospitals, to develop effective training program for semi-full-time safety managers, to accelerate practical use of reported events, or to develop a system to reduce adverse events.

Oral care and dental treatments are believed to play the crucial role in the prevention of respiratory complications especially for the elderly patients. The aim of this study was to examine the effects of perioperative oral care and dental treatments for the digestive surgery patients. We enrolled 169 patients who visited Nagasaki Prefecture Shimabara Hospital from February 2011 to January 2012. Speech-language-hearing therapists gave patients oral check-ups and advices for self treatments at the first medical examinations, and referred to local dental clinics when diagnosed to require professional dental treatment. 54 patients were referred to dental clinics, and 49 cases received dental treatment. Twelve cases among 167 control cases who did not received oral check-up and professional dental treatment have developed postoperative respiratory complications, whereas only two cases among 169 intervention cases developed postoperative respiratory complications. This intervention study showed a significant reduction of the risk of postoperative respiratory complications. For hospitals that do not have department of dentistry preoperative oral care, professional dental treatments in collaboration with local dental clinics can be effective methods for the prevention of postoperative respiratory complications.

Outcomes of the liaison critical pathway for diabetes mellitus are measured by good control of blood glucose, prevention of complications and non-interruption. Between May 2010 and December 2012, the liaison critical pathway was used in 70 patients (36 male and 34 female patients), with an average age of 66.5 years, disease duration of 8.4 years, and HbA1c (NGSP) of 9.3%. While treatment was interrupted in 5 patients during the observation, treatment was resumed in all these patients. HbA1c significantly decreased from 9.4 ± 0.3 % (mean ± SE ) on the day before the treatment using the liaison critical pathway to 6.8 ± 0.1 % at 6 months and 7.0 ± 0.1 % at 1 year after the treatment in 56 patients. An occurrence or aggravation of diabetic complications was observed in 5 patients, and these patients were treated with suitable medication and have since recovered. The liaison critical pathway may be useful for diabetes treatment and care in our city.

The reconstruction of the medical delivery system is proceeding by many kinds of functional differentiation and cooperation, aiming at utilizing the medical resource effectively. However the number of medical long-term care beds is insufficient in Yamagata, and the acute care hospitals demand the expansion of facilities with such beds to accept their discharged patients. We conducted the research for all hospitals of care-mix or chronic-phase type in Yamagata, examining operational realities of these beds. As a result, the proportion of admissions by the reasons except medical needs was over 30%. There were also over 40% of the patients continuing hospitalization in spite of their capability of leaving the hospital. The proportion of patients having high medical dependence was relatively low and such patients were mainly accepted in acute care beds. There may be some underlying causes related to tough management situations of hospitals that create this situation. However, one of the most important factors is that patients judged to be able to leave the hospitals stay in the medical long-term care beds. To make smoother the transition of the patients, we should comprehensively plan and practice the visions incorporating the various situations of nursing facility and home care in the given area.

At Fukuoka Rehabilitation Hospital's pharmaceutical department, in order to provide smooth and continuous medication practice, we have been providing a summary of paper, that includes the Pharmacology Management Guidance Information Summary (Patients' Medical Prescription History：PMPH)to other hospitals or nursing houses when patients leave the hospital.

As a result of providing the PMPH for 10 years, we evaluated the necessity of the PMPH by using the questionnaires attached. 90% of respondent of the questionnaires, needed the PMPH, but the low awareness of the PMPH was found in 24% of the respondents. Moreover, 67% of them thought the PMPH will be propagated in the future in Japan.

Summarizing and evaluating the answers to the questionnaires, we found that the respondents had different needs of information because each of them had different types of job；accordingly, we developed the new PMPH based on the needs of each type of medical staff.

We consider propagating the new PMPH, in order to maintain effective and safe pharmacotherapy as a medical cooperation tool.

Elderly patients with proximal femoral fractures are generally considered to have a greater risk for developing aspiration pneumonia. Therefore the assessment of swallowing function of these patients has been more important. We evaluated retrospectively the clinical usefulness of our original screening chart that we have developed for detecting dysphagia with 92% sensitivity and 68% specificity. A total of sixty-three patients over the age of 60 years who had fresh proximal femoral fractures between October 2012 and December 2012 were included. Of the 63 patients enrolled, 33 underwent assessment of swallowing function. Nurses in charge made an assessment of swallowing function by use of the chart immediately after admission and 19 of 33 patients (57.6%) were classified as having the potential for dysphagia. Subsequently 14 patients (42.4%) had a definite diagnosis by speech-language-therapist. During this period, aspiration pneumonia had occurred in three patients. The results of this current study are highly suggestive that our screening chart would be valuable for early detection of dysphagia. However, when considering the presence of aspiration pneumonia even after introduction of screening, further investigation will be necessary to make the chart more accurate in the diagnosis of dysphagia.

We experienced a food-borne norovirus outbreak in the hospital. In the morning of 7 February, 2013, our Certified Nurse Infection Control received reports of the symptoms of vomiting and diarrhea occurring in various divisions in both patients and staffs. The hospital Infection Control Team (ICT) judged this food-borne infection, reported the incident to the regional public health center and closed the hospital's central kitchen. The hospital director subsequently opened a special ICT center which worked as a prevention and staff education center as well as communication center to the regional public health center and mass media. The ICT also organized the daily staff meeting before office hour where all the main staffs were able to know the current status of the infection. Therefore each in-patient and his/her family members could be informed of the condition from their doctors or nurses directly. Since the central kitchen was closed and some of the kitchen staffs were found to be asymptomatic carrier of norovirus, cooking in the hospital was impossible. We served patients with ready-made meal. For the prevention of the recurrence of this accident, ICT examined the kitchen facilities and re-organized the cooking manual. Training of the kitchen staff was also performed by ICT. We did not charge the patients for the meal during the period of outbreak. For the patients who had norovirus symptoms, we also did not charge medical cost during symptomatic period and provided a small sum of money as compensation.

Osaki Citizen Hospital staff receives periodic vaccinations for measles, rubella, varicella and mumps in accordance with the Vaccine Guidelines for Infection Control by the Japanese Society of Environmental Infections. A new system was established using Microsoft Access to achieve precise and efficient vaccination management for more than 1,000 staff. Antibody testing and vaccination costs were paid by the hospital to improve the efficiency of vaccination. As a result, the vaccination rate for each disease was more than 70% during the period from July 2009 and August 2012. In the future, the implementation of antibody testing after vaccination, feedback, and the promotion of vaccinations to third party staff should be included in the program. Staff vaccination not only contributes in preventing their own health, but also in controlling secondary infections to patients. Vaccination management should be evaluated and implemented for an efficient and unhindered process.

Ashiya Municipal Hospital has a variable compensation scheme based on periodic staff performance reviews in order to increase employee motivation and enhance the effectiveness and efficiency of the hospital operation and management. The performance review is performed for each department at team level (not at individual level). Team goal is set at the beginning of each half-year period, and the actual achievement against the goal is reviewed at the end of the period. Actual achievement is assessed by reviewing difficulty of the goal and the level of achievement, and rated as the overall performance using a five scale rating. Based on the performance rating, 0% to 20% (by 5% increment) bonus is added to the variable compensation. Average bonus percentage added during six performance periods since this compensation scheme was introduced three years ago was between 6.47% and 10.22%.

Result of the employee satisfaction survey (64.9% collection) conducted for the staff subject to this compensation scheme was closely divided：47% answered review results were “Adequate” or “Mostly adequate”, and 41% answered “Not adequate” or “Mostly not adequate”. However, 74% supported continuing the compensation scheme, while 52% of which requested improvement of the scheme. 21% were supporting and 32% were against the introduction of the individual performance evaluation. 47% answered “Do not know”.

Performance based compensation scheme at Ashiya Municipal Hospital is substantially approved by its staffs. The scheme should be continued while improving the detail reflecting suggestions provided by staffs.

Matsusaka city hospital, which has 328 beds and is run under the Local Public Enterprise Law, introduced DPC/PDPS （Diagnosis Procedure Combination/Per-Diem Payment System；DPC/PDPS） reimbursement system in April 2008. Owing to the consciousness reform in the stuff, we improved management and succeeded in overcoming the deficit since 1989. To improve further the management, General Planning Office under direct supervision of the director was opened in April 2010. Here we report on the effect of breaking away from the medical work consignment.

Municipal hospitals expend a lot in commission fees；of these, the fee of medical practice is particularly high. Our hospital requires 140 million yens per year as medical expenses. We evaluated the degree of staff motivation and cuts in cost after executing direct management.

Before direct management, we employed 6 persons from the city and 50.5 persons from a contractor. Since the change to direct management, the number of employees was 9 as a full time and 48 as part-time. As a consequence, the total cost decreased by 30 millions, and there was a great improvement in the personnel motivation, much work in specialized areas, much more flexibility in the work and much more awareness in the staffs. The health information manager employs a total of 14 people, including a director of nursing, nurses, and our hospital is committed to improve on management.

We surveyed journal articles related to computerized support systems for prescriptions by physicians, prescription checks by pharmacists, and drug mixing in cancer chemotherapy published in the Japanese Journal of Pharmaceutical Health Care and Sciences and Journal of Japanese Society of Hospital Pharmacists between 2001 and 2011. The purpose of this survey was to clarify work contents that could be supported by computerized support systems. Furthermore, the articles were divided into 2 groups on the basis of whether the computerized systems were linked with the physician order entry (POE) system in order to compare function of computerized systems. Both computerized support system linked with the POE system and that not linked with the POE system were reported in 21 articles, respectively. The functions that supported prescription check and drug mixing by pharmacists were reported in both groups. Some of articles in which computerized support system did not link with POE system showed outcome of reduction in time of prescription check. On the other hand, with regard to functions that supported prescriptions by physicians were mostly confirmed in articles that reported on computerized system linked with the POE system. Therefore, it suggests that computerized system linked with the POE system was needed in order to support physicians.

In a man in his 60's a colonoscopy and CT scan revealed rectal cancer and cholelithiasis. Laparoscopy-assisted low anterior resection and laparoscopic cholecystectomy was performed；the patient was placed in the 20゜head-down position during the procedure. His left arm was placed along his left side and his right arm was abducted to 60゜.

Shoulder braces were placed over both acromioclavicular joints. The surgery lasted for 6 hours, while the head-down position lasted for 4 hours. After the procedure, the patient complained of left arm palsy. Left brachial plexus palsy was diagnosed from the clinical findings；the palsy symptoms diminished spontaneously within 3 days. Several reports mention neuropathy due to improper positioning during laparoscopic surgery. After this case, we routinely have a discussion with the surgeons, anesthetists and nurses regarding incorrect positioning. We determined the ideal position during surgery to avoid nerve injury due to mal-positioning.

When an electronic medical record system was introduced at our hospital, no PHA-based PDA (Personal Digital Assistant) for supporting nursing care was prepared. Laptop personal computer with Bluetooth compatible barcode reader was utilized for the certification of transfusion or infusion bottles. However, laptop computers were inconvenient since they were not portable. Recent improvements in smartphones enable application to nursing support system because of rapid wireless network speed and easy software creation. Existing smartphone nursing support systems used in other hospitals have different data structure and work under progressive wireless networks. These systems do not fit our environment because of the difficulty to modify the data structure, and to connect the appropriate access point rapidly when the electric wave from the initial access point becomes faint. In our environment, we prepared the forced connecting button to the appropriate access point. The user pushes this button when moving to the next area. When starting up the program, the user is required to input the user's ID and to read the barcode of user's password on the user authentication card with attached camera. Consequently, the patient's ID barcode on the wrist band and the certification barcode of the infusion bottle are read into the smartphone. If certification is verified, the smartphone displays the true mark. Entering the vital data and referring the order regarding any change in the patient's condition will also be available. Smartphone nursing care system provides ample communication speed. The entire process becomes more practical by changing the barcode format to QR code. This change leads to shortening of the recognition speed of the barcode. And, it can be available in most hospital wards by the forced connecting button. Android operating smartphone under conventional wireless network has the possibility of becoming a useful tool for all the medical staff.