4.1Medical Quality and Patient Safety

Our hospital considers patient safety the cornerstone of its medical service system and strives to create a highly trustworthy and secure healthcare environment as a key governance objective. We continuously enhance clinical risk management and quality improvement processes. Through an institutionalized patient safety management framework, our hospital has implemented a comprehensive patient safety incident reporting system, fostered a non-punitive reporting culture, and encourages all medical staff to proactively identify and report potential risks. These efforts aim to strengthen organizational learning and systematic improvement mechanisms.

In 2025, the hospital reported a total of 1,230 patient safety-related incidents, none of which reached the level of serious events. Medication-related incidents were the most frequently reported, primarily by pharmacists and nursing staff, highlighting the crucial role frontline clinical personnel play in risk identification and reporting. To continuously strengthen positive feedback mechanisms and foster a culture of safety, the hospital also promotes a patient safety reward system that recognizes staff who actively participate in reporting and improvement initiatives. A total of NT$184,500 in patient safety rewards was distributed throughout the year to encourage ongoing enhancements in medical quality and patient safety performance.

Patient Safety Incident Reporting and Mandatory Reporting Items at Our Hospital

1. When a patient safety incident occurs, the responsible staff must immediately assess and manage the patient’s physical and mental condition and complete an online patient safety incident report within 24 hours. Simultaneously, the unit supervisor or relevant personnel must be informed. The unit supervisor or department head must then determine whether the event is major and, if so, report it through the reporting system to the hospital director.
2. After receiving the report, the Medical Quality Unit conducts an initial review to determine whether it involves a patient safety abnormal event. If it does not, the supervisor of the reporting unit is notified, and the report is deleted. If it is confirmed, a patient safety report form is prepared and sent to the management unit for detailed analysis and implementation of improvement actions.
3. After the management unit responds, cases are classified according to the Safety Assessment Code (SAC) levels: cases at levels 1 and 2 must be submitted to the hospital director for approval; cases at levels 3 and 4 are submitted to either the Medical Department Director or the Quality Management Office Director for approval, depending on the type of event.
4. If approval requires a Root Cause Analysis (RCA), the Medical Quality Unit is responsible for convening the RCA meeting.
5. After the RCA meeting concludes, each management unit implements the defect improvements based on the meeting decisions and submits supporting documentation to the Medical Quality Unit. The Medical Quality Unit compiles these documents and prepares a review and improvement report for approval.
6. Once the handling of the patient safety incident is completed, the Medical Quality Unit monitors and manages the implementation of countermeasures and either continues oversight or closes the case for record-keeping.

The hospital’s reporting items are as follows:

Category	Description	Number of items
Adverse Drug Event	An abnormal event related to the medication administration process.	798
Fall Incident	Caused by an accidental fall to the ground or another surface.	86
Surgical Events	Abnormal events occurring before, during, or after surgery.	21
Blood Transfusion Incidents	Abnormal events related to the issuance of medical orders for blood preparation and the blood transfusion process.	4
Medical Care	Abnormal events related to medical treatment, therapy, and care measures.	37
Public Accidents	Incidents involving buildings, passageways, work objects, natural disasters, hazardous substance leaks, etc.	16
Public Security Incidents	Such as theft, harassment, abduction, assault, and homicide cases.	125
Harmful Behaviors	Such as verbal conflicts, physical attacks, suicide/attempted suicide, self-harm, and other related incidents.	33
Pipeline Incidents	Any incidents of pipeline slipping off, disconnection, misconnection, blockage, or failure to open.	30
Unexpected cardiac arrest	An event of cardiac arrest occurring within a medical facility that is not predictable based on the original disease course.	11
Anesthesia Incident	An abnormal event related to the anesthesia process.	0
Inspection and Testing	Abnormal events related to processes such as inspection, testing, and pathological slides.	26
Other Events	Abnormal events not listed above.	43

To improve the doctor-patient relationship and enhance the quality of clinical decision-making, our hospital actively promotes the Shared Decision Making (SDM) system. This approach increases the transparency of medical information and upholds patients’ rights to participate in their care. By implementing standardized communication processes and decision-support tools, we help patients fully understand their medical conditions, treatment options, and potential risks. This enables them to collaborate with the medical team in developing treatment plans. This patient-centered care model ultimately improves the quality of medical decisions and strengthens the trust between doctors and patients.

In addition, our hospital has consistently received external recognition for medical quality and professional development. Since 2023, six medical teams have been awarded the SNQ National Quality Mark certification. In 2025, our hospital also received awards for seven quality improvement projects spanning multiple specialized clinical fields. These accomplishments demonstrate our hospital’s ongoing success in medical quality management, clinical care process optimization, and cross-team collaboration, reflecting our long-term commitment and professional dedication to quality standardization and alignment with international standards.

Details of Our Hospital’s SNQ Awards Over the Years

Unit	Year	SNQ Award Theme
Nephrology	2025	The Key to Kidney Health: Utilizing a Digitally Integrated Nutritional Care Model to Optimize the Nutritional Status of Dialysis Patients and Prevent Acute Complications
Rehabilitation Department	2025	Creating Opportunities, Moving Toward the Future – Rehabilitation Robot-Assisted System for Improving Walking Ability and Cardiopulmonary Endurance in Patients with Subacute Stroke
Nursing Department	2024	A Brand New “Knee” Hope: Seamless Nursing Care Services
Surgery Department	2023	Multidisciplinary Integrated Medical Team Treating Colorectal Cancer ~ Continuous Medical Services Year After Year
Internal Medicine	2023	Afraid of pain and hesitant to undergo gastroscopy? Effectiveness evaluation of endoscopic examination under mild to moderate sedation
Pathology Laboratory	2023	“Precise” and “Rapid” Anti-Toxin Capability – Central Region Clinical Toxicology Testing Center

2025 SNQ Award Introduction:

• Key to Kidney Health: Utilizing a Digitally Integrated Nutritional Care Model to Optimize the Nutritional Status of Dialysis Patients and Prevent Acute Complications

Dialysis patients often experience poor appetite and improper dietary habits, which can lead to fluid and electrolyte imbalances as well as malnutrition. Common complications include anemia, abnormal potassium levels (both hyperkalemia and hypokalemia), hypoalbuminemia, calcium-phosphorus imbalance, and secondary hyperparathyroidism. Physicians and nurses in dialysis units possess specialized knowledge and skills, while dietitians are experts in dialysis nutritional supplementation and dietary education techniques. Beginning in 2024, dietitians will visit the dialysis unit quarterly to provide training on dialysis nutrition and education methods to medical and nursing staff. Patients or their families are encouraged to photograph their meals and upload the images via a social media group established by the dialysis unit using their smartphones, effectively creating a dietary diary. This approach facilitates communication between patients, dialysis nurses, and physicians, enabling the development of tailored dietary strategies to improve patients’ nutritional status.

• Creating Opportunities and Moving Toward the Future: A Rehabilitation Robot-Assisted System for Improving Walking Ability and Cardiopulmonary Endurance in Patients with Subacute Stroke

The rehabilitation department has introduced a robot-assisted system for walking training and cardiopulmonary endurance enhancement in patients during the subacute phase after a stroke. This system serves as an alternative to traditional walking training. The robot delivers repetitive, symmetrical, and quantifiable gait training, enabling patients to engage in high-intensity practice safely, thereby improving rehabilitation efficiency and treatment consistency.

This service integrates interdisciplinary teamwork, with physicians and physical therapists collaboratively assessing patients’ functional status, adjusting training parameters based on individual abilities, and monitoring treatment outcomes using objective indicators. Clinical results demonstrate significant improvements in patients’ walking ability and cardiopulmonary endurance, making the overall rehabilitation process more systematic and continuous.

The rehabilitation department also prioritizes patient safety and risk management by integrating robot-assisted therapy into existing rehabilitation protocols as a clinical decision support tool. This approach continuously enhances the quality of rehabilitation and fosters the development of patient-centered, high-quality rehabilitation services.

Our hospital’s 2025 Quality Control Circle competition categories and award achievements

Unit	Competition Category	Theme	Awarded
Ward 6	Pioneer Quality Control Academic Research Foundation – 218th National Quality Control Circle Conference	Reducing the Defect Rate of Combined Care Measures for Surgical Site Infection in Orthopedic Ward Knee Replacement Surgery	Excellence Award
Intensive Care Unit	Pioneer Quality Control Academic Research Foundation – 219th National Quality Control Circle Conference	Improving the Accuracy Rate of Targeted Temperature Management Technique Execution by ICU Nurses	Special Excellence Award
Pharmacy Department	Taiwan Pan-Island Medical Strategy Alliance Medical Quality Achievement Presentation Competition	Reducing Near-Miss Rates in Medication Dispensing	Honorable Mention
Intensive Care Unit	Pioneer Quality Control Academic Research Foundation – The 48th National Gold and Silver Award Quality Control Circle Selection Conference	Improving the Accuracy Rate of Targeted Temperature Management Technique Execution by ICU Nurses	Gold Award
Intensive Care Unit	2025 International Convention on Quality Control Circles (ICQCC 2025 TAIPEI)	Enhancing the Integrity of ICU Nurses Performing Continuous Venovenous Hemofiltration	Gold Award
Intensive Care Unit	International Society for Quality in Health Care Annual Conference ISQua 2025 (São Paulo, Brazil)	Enhancing the Integrity of ICU Nurses Performing Continuous Venovenous Hemofiltration	On-site Presentation
Nursing Home	Taiwan Healthcare Quality Association – 2025 Quality Improvement Achievement Presentation Competition	Enhancing the Integrity of Oral Care Provided by Nursing Home Staff to Residents	Excellence in Poster Award

2025 Intensive Care Unit Quality Control Circle (Enhancing the Integrity of ICU Nurses’ Performance in Continuous Venovenous Hemofiltration)

In 2022, the ICU introduced continuous blood filtration devices to implement continuous venovenous hemofiltration. To systematically improve the quality of critical care nursing, standard operating procedures and technical evaluation forms were developed. Through education and training, troubleshooting manuals, and practice equipment, the technical proficiency of nurses and patient safety were significantly enhanced.

Controlled Substances Management (SASB HC-DY-260a)

Our hospital manages controlled substances in accordance with the “Regulations on the Management of Controlled Substances” and related laws and regulations. We hold a controlled substances registration certificate issued by the health authority and have established a comprehensive management system and supervisory mechanism. Any changes involving registration details, including changes in responsible persons or controlled substances managers, are processed within 15 days as required to ensure all management procedures comply with legal requirements.

To enhance medical personnel’s proper use and management of controlled substances, the hospital’s Clinical Pharmacy Department organizes annual educational training courses for physicians, pharmacists, nurses, and other relevant medical staff. The course content covers compliance with controlled substance regulations, prescription management, medication safety, prevention of misuse, and identification of drug abuse. Through ongoing education and professional training, the medical team’s expertise and risk awareness in managing controlled substances are improved.

In clinical management, for patients suspected of substance abuse or at risk of drug dependence, the hospital has established an interdisciplinary assessment and intervention system. The medical team conducts thorough evaluations and implements appropriate interventions based on the patient’s condition. Prescription monitoring and medication management protocols are employed to ensure the rational use of controlled substances, minimize the risk of drug abuse and misuse, and balance patient treatment needs with medication safety.

Regarding drug storage and management, all controlled substances in the hospital are stored in dedicated controlled cabinets. Daily counts, regular inventories, and abnormality reporting are conducted in accordance with relevant regulations to ensure traceability of drug flow and accurate quantity management. These measures reduce the risks of loss, theft, or misuse and maintain the integrity and safety of controlled substance management.

Additionally, opioid antagonists and other drugs that can counteract the effects of controlled substances—although not legally classified as controlled substances—are included by the hospital in a high-alert drug management system. Clinical physicians and the pharmacy department collaboratively develop management and usage strategies, establishing appropriate handling procedures and monitoring mechanisms to enhance patient safety and improve the quality of clinical treatment.

Overall, through regulatory compliance, education and training, clinical monitoring, drug management, and interdisciplinary collaboration, our hospital has established a comprehensive controlled substances management system. We continuously strengthen medication safety and risk control capabilities. Moving forward, we will continue to refine controlled substances management processes, deepen medical personnel’s professional knowledge, implement patient safety and medical quality management, and ensure the safety, effectiveness, and compliance of controlled substances in clinical use. These efforts will further enhance the quality of medical services and the effectiveness of sustainable governance.

Our Hospital’s Quality and Safety Indicators for 2025

Quality and Safety Indicators (SASB)	Data for the Year 2025
Number of serious reportable events (HC-DY-250a.2)	0 件
Unplanned hospital readmission rate within 14 days after discharge	5.20%
72-hour emergency department return visit rate (HC-DY-250a.3)	1.14%
In-hospital fall rate (cases per thousand inpatient days) (HC-DY-250a.3)	0.005‰
In-hospital pressure injury incidence rate (HC-DY-250a.3)	0.03%
Central line-associated bloodstream infection incidence rate (HC-DY-250a.3)	0.013‰
Catheter-associated urinary tract infection rate (HC-DY-250a.3)	0.053‰
Surgical site infection rate (HC-DY-250a.3)	0.032‰
Pneumonia/ventilator-associated infection rate (HC-DY-250a.3)	0.034‰