We introduced new critical pathway for acute phase mild cerebral infarction in 2003. In this paper we reported the results of variance analysis of this pathway. The patient population included 41 patients who admitted and discharged at our hospital between November 2003 and July 2004. The presence of variance and its cause were retrospectively analyzed. Among 41 patients, 1 patient dropped from the critical pathway because patient developed pneumonia. Among 40 patients who used the critical pathway in full term, the patient with positive variance whose length of stay was more than 17days was 16 patients (40%). The patient with negative variance whose length of stay was less than 11 days was 10 patients (25%). The patient without variance whose length of stay was between 12 and 16days was 14 patients (35%). Among each variance groups, there is no age difference. Man is dominant in positive variance group. The causes of positive variance were the complications in 9 patients (56%) and the decision of the patient or family in 7 patients (44%). In the complications, there were 4 patients with diabetes mellitus and 3 of 4 patients newly introduced insulin therapy. One patient waited for a diagnostic test, and another patient waited for a transfer to other facility. There was only one patient whose cause of positive variance was severity of the disease; this means the prediction of outcome was acceptable. The factor of negative variance were mild disease in 9 patients (90%) and 1 patient admitted after infusion therapy at outpatient clinic for a few days by his wish. There was no medical staff factor in the cause of variance. We have a plan to rearrange the contents and usage of this critical pathway, and produce new pathway for effective management of the patients.

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The development of a critical pathway based on evidence and appropriate guidelines promotes improving the quality of life of patients and their families facing the problem associated with life-threatening illness. In a few weeks before death, it is important that palliative care staff may be working under the consensus of policy to deliver active and appropriate care and to avoid giving conflicting message to the family. Our critical pathway use the criteria to diagnosis for dying based on evidences identified by AHCPR classification type la to 3 and deceased 489-inpatient record analysis. There are two steps in our critical pathway. First compone nt mainly focuses the preparation to form comfortable hospital days for good death including discontinuing inappropriate interventions and non-essential medication according to agreed guidelines, re-planning of nursi ng care and reconfirmation of family view with their informed consent. Second step is ongoing care to dissol v e the problem to be suffered the patients from pain, dyspnea, respiratory secretion, vomiting, bowel distenti on, dry mouth, sleeplessness, confusion, anxiety and grief of their families and so on. In conclusion critical pa thway for dying patient have proven to reduce cost and hesitation of staff to cure or to care. In next setting we would determine and analyze variances.

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Advanced Parkinson's disease patients frequently suffer from various complications, such as on-off phenomenon and wearing-off (diurnal fluctuation), and drug induced psychosis (DIP). So they must often be hospitalized for the care of these phenomena. During these periods, the use of a critical pathway may be helpful for these patients. We made a critical pathway for the advanced Parkinson's disease patient who needed educational hospitalization for their long-term care system, and internal drug adjustment and control hospitalization. Then, we used the critical pathway for five patients of Parkinson's disease (Hoehn & Yahr stage III-IV) who were hospitalized for internal medicine adjustment for diurnal fluctuation, and/or for DIP, and we examined the indications. As the results, team approach for medical care among medical staffs (a dietician, a pharmacist, a physical therapist) was improved. It became easier to share between staff information about the effects of drug control. We achieved standardization of patient evaluation by using Unified Parkinson's Disease Rating Scale (UPDRS) and the evaluations were useful in the therapy effect evaluation. On the other hand, there was a significant variation in the five cases and so tailor-made therapy was needed for the Parkinson's disease patients. The application of a critical pathway will bring a profound quality improvement to medical staffs and hospital management, and of course to Parkinson's disease patients.

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Several incidents in managing infusion pump systems have been reported, including excessive administration due to setting errors or delays in finding system troubles.
Wrong usages of the systems directly deteriorate the nursing quality in managing the infusion, so the indication for using the pump should be standardized by assessing their necessities. A possible factor of these incidents should be overdependence of nurses on the systems, which was investigated by confirming the nurses' attitude at using the infusion pump systems with questionnaires.
In the group managed with the pump (203 patients), the intervals of nurses' rounds during the infusion were within 30minutes in 36patients, 30-60 minutes in 86 patients, 60-120 minutes in 62 patients and the longest interval was 180 minutes. In the group managed without the pump (47 patients), those were within 30 minues in 23 patients, 30-60 minutes in 16 patients and the longest interval was 120 minutes. In the group managed with the pump, sounding alarms were reported in 70 occasions, which were 12 bubble detection, 25 obstructions and 33 completion of the set volume. For 74 patients in the group managed with the pump, the necessities of pumps seemed obscure, however nurses still considered it necessary for 33 patients among them. These results indicate the intervals tend to be long if the pumps are used, and several nurses think the pump is necessary even without justified reasons.
After establishing and notifying to nurses “the criterion for using injection pump systems” considering the patient safety and QOL during the hospitalization, the rate of using the pump has dropped from 18.5% to 13.6%. The rate of unjustified pump usage has also dropped from27.8% to11.1%. We find these changes have resulted in the improvement in assessment ability for managing the infusion.

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In the Medical Liaison Center Tokushima University Hospital, established in 1999, a total of 2074 nursing consultations were accepted from 1999 to 2005. The problems we found in these 6 years were; 1. lack of consultants, 2. diverse and manifold inquiries from each client, 3. too many inquiries in limited office hours, etc. To improve the situation and deal with such diverse inquiries as promptly and properly as possible, we analyzed the details of our consultations, classified them into several categories, and developed a nursing consultation software, which provides users with information including answers to inquiries or site links to proper authorities where clients can obtain additional information. As a result of software evaluations, we found that the software functioned effectively, by using it on the Internet, as information sources not only for consultant nurses but also for medical staffs in and outside of our hospital, student nurses, and patients or their families. We also found that the software could reduce time to get to proper information and respond to manifold inquiries.

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The History of laparoscopic surgery in gynecology is old and the most of procedures were completed in 1970s.In our department, we introduced laparoscopic surgery since 1990's and brought up training and a practiced of operative procedure.
Corresponding to these purposes we have kept the security of demand of the patients and promoted efficiency and improvement of duties to cope with demand to enlarge. We disclosed information for two types of customers (patient and medical doctors) positively to reclaim demand of laparoscopic surgery. Critical path was used to manage the laparoscopic surgery that increased rapidly. Various types of critical path were used to standardize the task in outpatient clinic, administration and operating room. We were able to share the information and promote the efficiency among the patients, doctors and paramedics.
The cases of laparoscopic surgery in our department increased approximately 10 times after ten years from 1993. We managed the laparoscopic operation the smallest staff by these promotions of efficiency smoothly.

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DPC “Diagnosis Procedure Combination” is an inclusive payment system of the acute period hospitalization in our country. It was introduced into our hospital in July, 2004. At that time, we were requested that a critical path was assumed to be a corresponding type for DPC.
Our committee defined the following three items as concrete conditions for it.
1. The number of days in the hospital is set to less than “Hospitalization period II” of DPC.
2. Among pre-operative and pre-discharge inspections, possible items of them are shifted to the outpatient department.
3. The standard of leaving hospital and the target of leaving hospital day are clarified.
The concrete improvement point of the existing the total-knee-replacement path revised along above mentioned conditions was shown as an example.
When DPC will be newly introduced in your hospital, it is not difficult to change the existing path to DPC path, if existing path is already revised properly after variance evaluation.

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As standardization of chemotherapy regimen is likely to be indispensable at present, we introduce our system for standardization of chemotherapy. On the practical side, our system is consisted of the following four parts; 1. input of decision of chemotherapy, 2. preparation of medicine in the aseptic dispensary, 3. display of calculation of the dosage of chemotherapy, 4. prescription of injection on ordering system. The pre-treatment of chemotherapy and hydration were standardized in each protocol, and then unnecessary variations were excluded. Furthermore, using the information technology, the dosage and the schedule of chemotherapy were automatically calculated. The standardized liquid composition linked to the prescription of injection. The development of our system can offer a risk management benefit.

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To build up a close referral relationship between clinics or hospitals and an university hospital, it is very important for doctors at a referred hospital to write back to those referring physicians with elaborate reports concerning referred cases.
About new report checking system, the questionnaire was carried out for doctors. After the introduction of this system, it became easy that doctors writes reports. The number of the reports which was not written after a close examination decreased. The complaint from reffering doctors decreased. Temporary evaluation was obtained to the new report checking system.

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When the poor sterilization happened, it is necessary to recall the items as soon as possible. Although immediate recall is important in the view of risk management, there has been few reports about the actual conditions in case of recalls. On recalls, several problems are expected to happen, such as the place to be recalled, prediction of poorly sterilized items, cooperation among the relevant sections and present condition of recalls.
Concerning these backgrounds, we practiced a case of recall assuming that a bad sterilization happened. After that practice, it has become possible to analyse the present condition of the reclamation of the instruments. It has also become possible to make the data to rise up the level of sterilization.
The necessity of the investigation of the sterilization process and the assurance for sterilization was strongly realized, in order to supply properly the reclamation instruments at clinical scene properly.

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With the introduction of electronic medical records in September 2003, our hospital began to function with an IT system in the hospital environment. However, there have been many cases in which omission of entry of activity has been suspected. This problem not only considerably increased work associated with verification by medical processors but also caused concern regarding the reliability of consistency between actual and recorded injections and accuracy of drug control.
With updating of our drug control system, we took measures to prevent omission of entry of injection treatment and entry errors in electronic medical records by checking released drugs based on inventory control.
This system management revealed that entry of injection treatment was omitted at a rate of 4 to 5% of injections prior to system operation, and that this system thus prevented omission of entry of injection treatment. It was also confirmed that the error rate was 1 to 2% for data entries, which were made after using injections stored for emergencies.
Careful data entry assures the authenticity of medical records. Because our system improves accuracy of control, we expect that it can also be used for automatic ordering.

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There are a lot of scenes and problems that are hard to correspond to patients in patient-oriented guidance of taking medicine in the system of present outpatient managemanet. It is correspondence to the question not made to the physician in charge and guidance of taking medicine that has two or more indications, and to uncertain situation of notification on the cancer patient. The pharmacist (health insurance pharmacy, abbrev: the pharmacy) cannot share the name of a disease and the condition with the charge hospital and clinic unlike in hospital. The collecting information of diagnosis depends on listening to the case history gropingly from the patients in daily life as a result. It thought whether the thing caused patient's uneasiness and disadvantage, and this time we did the patient questionnaire survey and made and operated a new transmission tool of the outpatient diagnosis information for trial purposes.
The questionnaire survey was executed by the self-filling for 200 people. Its results clearly showed that 81% patients of all convinced that the pharmacist also understood his name of a disease and condition, and 76%'s hoping moreover to want the pharmacist to understand their name of a disease and condition for securing the safety of taking medicine.
Besides, an original format that transmitted the name of a disease and the prescription intention was operated in cooperation with the department of urology of the general hospital. The information of 79 people, 126 cases has been received for 19 months. All staff in the pharmacy was experienced that they could explain and guide suitably to be matched to the state of each patient. Using the tool has the content of guidance between doctors and pharmacists be correspondent, and we got the prospect to be able to come up to the patients' expectation.

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Career development of hospital administrators has not attracted attention in Japan although it has been an important subject in the hospital management.
This research was conducted to identify models of career development of hospital administrators by reviewing leading literature and conducting field studies in several countries.
As a result, it was indicated that the research on work experience, capability, and knowledge which are desirable for hospital administrators was still insufficient in Japan. According to the field studies in Japan, Human Resources development programs based on classified training are popular but could not find one with a clear definition of the capability and the qualification for hospital administrators. Therefore it was not clear whether or not those HR development programs had contributed to the career development of the hospital administrators effectively.
On the other hand in the other countries, the role of the hospital administrators are clearly defined as well as their qualification and compensation, and the career development is mostly taken place as a personal issue. Collaboration with academic institutions such as business schools offering MBA and MHA also takes important roles in terms of career development of the hospital administrators.

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Wrong person, wrong site, and wrong procedure of the operation are uncommon adverse events, but these are very shocked at the occurrence of them. The purpose of this study is to clarify the usefulness of “5 steps” in the Veterans Affairs in U.S.A. to correct surgery. At the days to hours before procedure, the consent form is administered and executed properly and the consent form must include patient's full name, procedure site, name of procedure, and reason for procedure (Stepl), and the operative site is marked (Step 2). Just before entering operating room or treatment room, the patient is actively identified using required techniques (Step 3) and operating staff must confirm the patient's full name, date of birth and marking site. Immediately prior to procedure, a “time out” briefing is conducted in the operating room prior to starting the operation or invasive procedure, and operating staff must confirm the presence of the correct patient, the correct site has been marked, operating procedure and the availability of the correct implant, if applicable (Step 4). Finally, two or more members of the operating team review imaging data prior to the surgical procedure (Step 5) and confirm that the images are correct and properly labeled.
Because of simple intervention and priceless, this method will be very contributable if misidentification of patients, inappropriate surgery are to be reduced.

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