In order to identify whether a relationship exists between nursing practice abilities and the occurrence of Medication errors (oral and injection), we developed the hypothesis that the occurrence of Medication errors is lower in wards where there is a high proportion of nurses whose nursing practice abilities are high and also that the opposite holds true. This study was repetitive survey design. Data were collected at three time points, in January 2007 and May and July in 2008；months known to include high and low occurrences of adverse events. Data were collected daily for one week in each month. Six acute hospitals were selected from the list of the hospitals by the chance method, and 46 general wards participated in the research. A questionnaire survey was conducted with staff nurses in each ward excluding the nurse manager in order to the estimate nursing practice abilities. Data regarding the Medication errors (oral and injection) were collected as the dependent variables, and extent of nursing care need, and number of medications were collected as risk adjustment data. For the analysis, we defined a “high proportion of upper-middle level nurses” to mean there was a high level nursing practice abilities on a ward and this was used as the independent variable. We analyzed data for Medication errors in a week-unit for each month by using the generalized estimating equation with Poisson deviation in order to determine the relationship between Medication errors (oral and injection) and independent variables. No relationship was found between the proportion of upper-middle level nurses and “Medication errors (oral)”. However, a relationship is seen during the daytime：when there is a higher proportion of upper-middle level nurse on the wards, the number of “Medication errors (injection)” is lower.

Due to the progress of medical functional differentiation as medical policies, large hospitals have been required to reduce and specialize outpatient functions and to concentrate on inpatient medical care. However, no progress has been achieved in this regard.

The purpose of this study was to investigate the reduction in outpatient sections, which is regarded as a part of hospital functional differentiation, and the influence of the functions of large hospitals and regional medical systems on the reduction of patient consultation for mild symptoms in the outpatient sections of large hospitals.

The subjects were 82 large national hospitals with 200 or more general beds during a period from April 2013 to March 2014. Diagnosis Procedure Combination (DPC) and outpatient claim data from the hospitals were analyzed. First, patients with mild symptoms were identified and the patient consultation situation was clarified. Next, multiple regression analysis was conducted to investigate the proportion of patient consultations, and hospital and regional medical system factors. In addition, patients with mild symptoms were defined as those who received possible medical care at clinics. We developed an evaluation method using outpatient claim data.

The proportion of the patients with mild symptoms visiting the hospitals was 38.12% (SD＝9.2%). Factors that influenced consultations included chemotherapy rate （β＝-0.55，p＜0.01）, surgical rate （β＝-0.41，p＜0.01）, efficiency index （β＝-0.25，p＜0.02）, and general beds ＞ other beds （β＝-0.22，p＜0.02）. In this model, R^２ ＝ 0.56. These variables indicate the quantity of acute-stage medical care, where higher values indicate lower consultation rates.

This study indicated that hospital functional differentiation can be promoted by decreasing the number of patient consultations for mild symptoms, which enables further enrichment of acute-stage medical care.

Aspiration pneumonia (AP) that develops during hospitalization causes an increase in the need for additional medical resources. However, information about these resources is not sufficient as limited studies have estimated them quantitatively. Against this background, the present study aimed to quantify additional medical resources used for AP developing during hospitalization.

We analyzed DPC data directly obtained from the investigated facilities. Patients who had developed AP while being hospitalized were matched with control subjects by disease, type of surgery, and patient attributes. Based on the differences in average values shown by these 2 groups, we estimated the hospitalization period and quantified additional medical resources used.

As a result, the average period of hospitalization due to AP developing after admission was 17.2 days (11.6 to 22.8 days) [95% CI]. In addition, the average cost of hospitalization due to AP was 619,000 yen (397,000 to 842,000 yen) [95% CI].

In the present study, we quantified additional medical resources used for AP developing after admission. The study results could be widely used as basic material for medical management supporting the prevention of AP during hospitalization.

Unified liaison critical pathways for multiple diseases were operated in Gifu second medical area (a population of about 800,000 people) by ‘Gifu area medical association liaison pathway organization’ since 2006. ‘The Organization’, based on the Gifu City Medical Association and inter-hospital cooperation network, is composed of several working groups of expert doctors on myocardial infarction, viral hepatitis, stroke, femoral neck fracture, urological diseases, five major cancers, diabetes and COPD. Secretariat system of ‘the Organization’ is composed of supervising steering committee of representatives of each group, and inter-hospital cooperation support network. In addition, ‘the Organization’ held a pathway coordinator training course to further promote the scheme.

Here, we report the status of the ninth year of reciprocating-type pathways between the specialist and the clinic. Number of all reciprocating-type pathways operated is 3207 cases as of March 2015, marking an increase around 400 cases in six months. In recent years, five major cancers, especially stomach, colon and breast have been increasing. Participation status of clinics, out of the total 606 clinics in this area, is 31.8% in colorectal cancer, and 31.5% in breast cancer. Clinics which participated in any of the reciprocating-type pathway have surpassed majority, increased up to 56.4% (342 clinics). Each clinic receives liaison pathway from 1 to 5 (average 2.01) hospitals, and receives 1 to 9 (average 3.42) types of pathways. Future challenges include outcome evaluation, maintenance of the ‘the Organization’, and actions towards the establishment of integrated community care system.

We analyzed the changes in 24-h physical activity and number of steps of patients hospitalized at Kawanishi City General Hospital to obtain reliable information on fall risk in hospitalized patients. Twenty-four inpatients (male 14, female 10；median age, 64.5 (39-92)) were studied. Major disorders were as follows：hepatic disorder 5, cataract 4, cancer 3, diabetes 2, and infection 2. Patients wore a physical activity monitor at their waist. Physical activity (METS：metabolic equivalents) and number of steps in 24 hours were monitored continuously until the day before discharge. The number of steps and the physically active ⊿METS during the 12-h night period (18:00-06:00) were about half those during the 12-h daytime period (6:00-18:00). The ratio of physically active ⊿METS at night to the number of steps in the daytime of patients with low risk assessment for falls was lower than that of patients with high risk assessment for falls, which suggests a relationship between physical activity at night and fall risk. The ratio of physically active ⊿METS at night to the number of steps in the daytime in 3 patients who experienced falls was significantly higher than that of patients who did not experience falls. These results indicate that the ratio of physically active ⊿METS at night to the number of steps in the daytime might be one of the indicators of fall risk.

The Kawaguchi Municipal Medical Center implemented a hierarchy-based education and training program for healthcare quality and safety. In this study, we consider the management of daily processes to be fundamental in maintaining and improving healthcare quality and safety. To ensure good quality of healthcare services, it is necessary to build a Plan-Do-Check-Act (PDCA) cycle and structure daily management for continuous improvement. We implemented daily management along with policy management in 2012.

We organized training in classes and held some individual meetings to examine the progress of daily management, especially focusing on data collection and observation；56 managers completed daily management training in these phases. Results show that individual meetings are effective in overcoming difficulties.

The time of the big healthcare reform has come for a hospital. Daily problems and task needs to be solved much earlier than before. Therefore, we hold management meeting every week for improved quality management, and performed PDCA cycle systematically. We assess fluctuation of KPI (Key Performance Indicator） every week, share information and have taken the measures according to demand, such as establishing emergency medical system, and ensuring specialists about the health care system shortage in the region, such as melena, gastrointestinal diseases and stroke. Index on patient composition rose by securing the medical system for serious most common disease. Index on average number of days for hospitalization rose by expanding post-surgery referral cooperation, starting rehabilitation early and promoting reverse referrals. It led to offer shorter and good quality re-hospitalization. Function grade coefficient II of DPC/PDPS (Diagnosis Procedure Combination/Per-Diem Payment System) rose. Increased index on patient composition and index on average number of days for hospitalization represents the average length of hospital stays and the severity, and our results suggests that hospital management meetings are very effective. From now on we will also concentrate on analyzing various information and date, and the future function of the hospital.

It has been 6 years since 43 medical assistant clerks had been introduced to 23 medical departments in our hospital. Thereafter, two problems were revealed. One is that we are not able to grasp the medical assistant clerks' real abilities clearly；the other is that it is uncertain if doctors are demanding the medical assistant clerks' additional assistance. Therefore, we performed a questionnaire survey on both the doctors and medical assistant clerks in order to investigate whether present education system is working well and effectively on lightening doctors' workload and to examine the details of medical assistant clerks' duties for the future.

Overall, as a result, medical assistant clerks received a high evaluation for their present outpatient work and the result also indicated the possibility of expanding their activities in the future. Moreover, we also carried out a comparative study of the medical assistant clerks' accuracy on their work by comparing final documents made by the doctors and the medical assistant clerks. The work rated more than 80 % “accurate” are as follows：consultation reservation order and output of examination results (85%), output of reservation document (82%), data organization (74%), input of medical record at re-visit (72%) and input of medical record at the first visit (67%). Furthermore, the secretarial work gained a favorable result：careful consideration for doctors' smooth consultation (81%) and appropriate reservation arrangement (67%). Additional duties which doctors think the medical assistant clerks can cover include more advanced medical knowledge, consequently, we need to increase knowledge and improve our skills.

For cost-suppression purposes, Shimane Prefectural Central Hospital has been categorizing single-use devices into strictly single-use and re-usable. Materials other than that is temporarily placed in patient's body or in their blood vessel, that may be re-claimed for insurance, is past expiration date-were unused or recycled, and materials that could not be sterilized for safe re-use or reproduction, were sterilized and reused under strict control. However, with the publication of “Regarding the republication handling of single-use medical devices” issued in June 2014, the hospital began to adhere to the package instructions, and to fully practice single use. After the system change, our team followed the movement of 73 medical supplies that was changed to single-use and evaluated the influence on material costs. Results showed a small rising tendency due to initial increase in cost to stock medical materials. We estimated the rise in cost to be 40,320,000 yen. The actual increase in cost was 16,740,000 yen, covering 0.93% of total expense. Although the impact and effects of the strict adherence to single-use instructions provided by the makers was not made clear, we consider advocating for review of usage procedures, price negotiation, and switching to recyclable materials. In light of the recent revision of the medical treatment fees and increase in consumer tax, to optimize the costs of medical materials, particularly the materials unclaimable by insurance, is important.

We designed a de novo hepatitis B prevention system and did outcome evaluation of the system. We have been informing the attending physicians whenever HBV-DNA was positive to prevent de novo hepatitis B, and held lectures to inform on de novo hepatitis B. However, adherence rate to guideline of de novo hepatitis B was very low at 20.3%. We then inserted an on-screen alert system for de novo hepatitis B in our electronic medical recording system. Consequently, the adherence rate improved up to 34.2%. Next step, we put an alert sheet under clear cover of the medical records to examine HBsAb, HBcAb and HBV-DNA. Adherence rate to guideline markedly improved to 63.8%. After initiating this system, three cases were successfully treated before de novo hepatitis B break out, so we think this system is effective to prevent de novo hepatitis B to some extent. We will continue improving de novo hepatitis B prevention system to inform physicians before starting chemotherapy.

Since 2012, we have trained staff at Yuai-Kai Foundation & Oda Hospital, Saga, Japan in basic life support (BLS) through an annual lecture. The effectiveness of this training, however, has not been evaluated, and we experienced problems in executing resuscitation in a recent case.

We therefore changed the format of the training from a lecture to a series of practical exercises in small groups of three or four people. Those attending the training were all staff in the hospital excluding medical doctors. We used an adult-sized mannequin for CPR simulation and an automated external defibrillator as training tools, and, also gave a detailed lecture on the skills. We assessed the effectiveness of the training using a detailed simulation of a cardiopulmonary arrest that had occurred in our hospital. Participants took part in the simulation both before and after the training, and we filmed them to check skills and speed of response. The trainees answered questionnaires on a zero-to-ten scale about their knowledge of BLS, willingness to provide it and confidence in their ability pre- and post-training.

Of 239 hospital staff eligible, 220 (92%) attended. According to their responses to the questionnaires, their knowledge, willingness and confidence all improved. In the simulation, the speed at which participants confirmed the presence of respiration and started chest compressions improved after training.

These results suggest that providing training using practical exercises in small groups of three or four people improved the participants' ability to provide basic life support.

We report on the systematic trial for the HAD development prevention that start before the hospitalization. In aging society, prevention of the hospitalization-associated disability (HAD) is an important element of caregiving as it makes bed rest by hospitalization, and would contribute to maintain or raise the quality of life of elderly patient. About 20-40% of the elderly patients hospitalized for acute medical illness develop HAD. Once developed, HAD is difficult to improve and prevention of HAD is an urgent issue to discuss. We have developed a screening sheet for identifying at-risk patients of HAD. This sheet consists of three elements；exclusion criteria, a criterion of judgement, and an intervention plan. The flow chart was developed based on the screening sheet so that patients could be divided into three groups：1) no intervention group, 2) self-rehabilitation group, and 3) physiotherapist intervention group. The self-rehabilitation group used exercise program that nurses collaborated to construct with the orthopedist, dementia specialist, and the physiotherapist.