The Japanese Journal of Clinical Dialysis Vol.25 No.6(2)

Theme Dialysis Safety Management Issues
Title What should we do for safety management after the occurrence of a severe medical incident in the dialysis division ?
Publish Date 2009/06
Author Toshio Shinoda Dialysis Center, Kawakita General Hospital
[ Summary ] There are many medical incidents which may not necessarily be attributable to management failures. Immediately after the occurrence of a medical incident, it is necessary to make a report to the hospital administration concerning that incident in addition to treat the injury. It is also necessary to consult with both the administration and the medical staff members concerning implementation of countermeasures. During the first consultation with patient's family members, regrets should be expressed in cases not involving failure of medical management. An apology should be made in cases where medical management failure has occurred. The probable cause of the incidentand the countermeasures to prevent similar incidents should be investigated by a hospital committee. A report concerning the detail of the incident and the countermeasures against it should subsequently be provided to family members. In cases involving unexpected patient death, a report must be made within twenty four hours to the appropriate law enforcement authorities. In case involvingin hospital infection with hepatitis B and/or C, a report must be made to the proper public health authorities within seven days of diagnosis.
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