Process indicators are frequently used to evaluate and improve the quality of care. However, choosing an effective indicator is difficult, and measuring ineffective process indicators may not only fail to improve quality but also do harm to patients and the healthcare systems through lost opportunity costs and inadvertent adverse effects. Process indicators in the Core Measures of the Joint Commission in the United States exemplify the difficulty in selecting effective indicators and provide historical examples of successful and unsuccessful cases. Learning from analyses of those indicators, the Joint Commission developed criteria to evaluate the effectiveness of process indicators and to choose Accountability Measures: research, proximity, accuracy, and adverse effects. When selecting process indicators to be measured, in addition to these four dimensions, one also needs to consider sample size, validity and reliability of the measurement, cost, feasibility and sustainability, and alternative processes. Using these criteria, the process indicators need to be rigorously evaluated for the effectiveness before implementation and continuously monitored after implementation.

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Objective: Education about medical instruments is thought to be one way to reduce medical accidents due to such medical instruments. Simulation-based medical education for doctors and nurses has been reported, but there are few reports on medical students. Although nasogastric tube is described in the medical education model core curriculum, medical students have little experience with nasogastric tube. The curriculum describes: "[students] can outline types and principles of main medical equipment." While infusion pumps and syringe pumps are commonly used, and medical accidents are frequently reported, but there are no reports concerning how medical students are trained to use infusion/syringe pumps.The purpose of this study is to examine the significance of simulation-based education for medical students on using infusion/syringe pumps and nasogastric tube. Methods: Our subjects were 82 medical students. We required the students to insert a nasogastric tube into the simulator and to handle infusion/syringe pumps, and we reviewed nasogastric tube placement, free-flow, and the siphon phenomenon. We administered three tests: before practice, after prior learning, and after practice. Results: The accuracy of review of nasogastric tube placement was significantly increased among students before practice, after prior learning, and after practice. The accuracy of siphon phenomena and nasogastric tube placement was increased as well. Conclusions: Simulation-based medical education for medical students in nasogastric tube and infusion/syringe pumps is significant to understand procedures that are difficult to experience in clinical practice but that must be properly executed.

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Study objective: The aim of the present study was to investigate the effects of behavioral interventions to reduce the number of alarms of patient monitors for the nurses. Design: AB, ABA design. Participants: Surgical ward nurses. Intervention: Experiment 1: Introduction of the monitor function that automatically displays the instruction to reduce the number of alarms and the presentation of another procedural material to the nurses. Experiment 2: Introduction of the scaled alarms depending on the priority values under specifically categorized conditions. Measure: The number of alarms per bed. Results: In Experiment 1 and 2, the possible effects of the interventions were recognized. Conclusion: Visual notifications on the display with manual distribution to the nurses were not effective enough. More aversive stimulus for low priority alarms, feedback for individual behavior, and combination of visual and auditory stimulus will be needed.

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Purpose: For the purpose of preventing recurrence of general anesthesia related accidents and for promoting further medical safety, medical precedents related to general anesthesia have been collected and probed into the causes and measures of the accidents, considering methods for them by utilizing P-m SHELL model (P: Patient, m: management, S: Software, E: Environment, L1: Liveware, L2: other Liveware), which is an analyzing model for medical accidents. Methods: The judicial precedents associated with general anesthesia were collected utilizing online database and electronic data book, based on the key-words of general anesthesia, anesthetics and anesthesiologist. The extracted data were classified according to their contents and then their causes were analyzed by using P-m SHELL model. Finally the causes of the accidents and measures for them were discussed with literature review. Results: As a result of analyzing the precedents by utilizing P-m SHELL, the greatest percentage of the accidents were caused by L factor. After L factor, P-factor, m-factor, and H-factor followed. No doctors’errors were judged at all in the precedents caused by P factor. On the other hand, doctors’errors were judged in all the precedents in which doctors’errors (L factor) had been clearly shown. Conclusion: It is essential for anesthesiologists to assess the patient risk appropriately and to avoid the human errors. Also it is important to improve m, H, S, and E　factors so as to prevent accidents caused by L and P factors. The P-m SHELL model is considered useful since it can be helpful to extract the various causes of accidents in the background.

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This study clarifies the social problem of nosocomial infection. The data for analysis were newspaper articles found through searches for the keyword “nosocomial infection.” The social problem of nosocomial infection began when doctors alerted the public to the problem of methicillin-resistant Staphylococcus aureus （MRSA） in the 1980s. In the 1990s, newspaper articles on the subject including articles on lawsuits began to appear. As a result of public interest in the subject, the Ministry of Health and Welfare issued a notification to the public on nosocomial infection control. The features of the social problem of nosocomial infection include that a sub-category of nosocomial infection, nosocomial infection caused by resistant bacteria, became a social issue. Doctors recognized that nosocomial infection by resistant bacteria is a problem beyond the responsibility of individual medical institutions and medical staff.

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[in Japanese]

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The purpose of this paper is to share having learned individually as the chairperson of the investigating committee of Gunma University hospital between August 2015 and July 2016. An accurate illustrate of the commission report was not described in this paper. The conception of clinical governance was described as well as viewpoints, structures, processes, and analytic skills of the investing committee.

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Quality improvement and patient safety are top priorities of medical institutions. Patient safety education for nurses has gradually been incorporated into not only in-service continuing education but also basic nursing education. However, issues such as collaboration with educational and clinical institutions and training of human resources engaged in patient safety education still persist. Therefore, we discussed the implementation of patient safety education for nurturing student nurses into experts through the following pioneer efforts: 1) collaboration between the nursing staff and faculty during clinical training, 2) drafting a basic nursing education curriculum that incorporates the concept of patient safety in the educational content of multiple specialized subjects, and 3) a general risk manager’s intervention in education of both student and service-continuing nurses. It is necessary to recognize patient safety education as an important element of nursing professional education and work toward building a continuous and seamless educational system for nurturing student nurses into expert nurses. Thus, it is essential that the faculty, nursing staff-in-charge of clinical training, general risk managers, and nurse managers share knowledge and skills of patient safety education and closely collaborate to build a system for educating nursing students and staff. This report is the summary of the panel discussion 10 of the 11th annual congress of Japanese Society for Quality and Safety in Healthcare.

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