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医療事故調査制度について

New system to ensure patient safety by investigating accidental death in Japan 

日程2017年4月13日(木)

演者: 

後 信
公益財団法人 日本医療機能評価機構 執行理事
九州大学病院医療安全管理部教授・部長

 

Date:  
13 April 2017

Presenter: Shin Ushiro
Professor Shin Ushiro, Executive Board Member - Japan Council for Quality Health Care, Professor and Director, Division of Patient Safety, Kyushu University Hospital

 





参加者の感想
Participant Feedback

医療事故調査制度の現状がよく分かりました。医療過誤を恐れて報告件数は少ないと聞いていましたが、想像以上に報告されていることに驚きました。また、個人の責任を追及するものではないという点で共感が持てました。
 
平井 治
副師長
 
“This webinar clearly explains the current state of medical adverse reporting systems. I was surprised to hear that the number of reports was higher than expected. I have heard that only a low number of reports are recorded as medical practitioners are afraid of being sued for malpractice. This webinar also made it clear to me that the reporting system has not been established to blame or attack medical staff for any adverse medical events that occur."  

Osamu Hirai
Deputy Chief Nurse
______________________________________________________________________________________

医療事故調査制度の現状を知るとともに、その仕組みがよく理解できた。また、調査を行う上での費用負担や手間、手続きの概要がわかり、実際に調査を行うことの難しさを感じた。
 
安食 愛彦
臨床検査技師
 
“This webinar helped me to clearly understand both the current state of medical adverse event reporting as well as the reporting system itself. I also learnt that the cost, time and procedures necessary for investigating adverse events can create difficulties.” 
 
Yoshihiko Ajiki
Medical Technologist


 

Webinarについて
About the Webinar

2015年に医療事故の再発防止を目的として医療事故調査制度が開始された。国では年間1,300-2,000件の調査が行われると試算された。開始後1年を経て、運営状況に関する統計が公表された。報告件数は、1/3-1/5の件数で推移している。この理由として、報告範囲が不明確であること、報告後の院内事故調査の負担が大きいこと、報告書が紛争を誘発することへの懸念等が指摘されている。それらの点を含め、医療事故調査制度の現状について述べる。

The Japanese government launched a new investigation of accidental death in medicine based on revised "Health service law" in 2015. The system aims at promoting patient safety by crafting preventive measures based on the investigation. Initially, 1,300-2,000 death cases were expected to be subjected to the investigation. Now, one year has passed since it was launched. The operating organization recently published statistics of the system to show current status of the investigation. It was notable that only 388 cases were registered within the first year for the investigation which corresponds to 1/3-1/5 of estimation by the government. Ambiguity of criteria for reporting is focused for a major reason of underreporting. In addition, concerns on too much burden of investigational work in medical institutions and allegedly possible conflict ignited by compilation of in-depth investigational report still lingers and may explain the reason. The current status of the system is to be reviewed.



演者について
About the Presenter

 

 後 信 (うしろ しん)
(公財)日本医療機能評価機構 執行理事
九州大学病院医療安全管理部 教授・部長
九州大学卒、医博、MD、PhD.
研究領域:医療安全、有害事象報告システム、無過失補償

 


Professor Shin Ushiro is Executive Board Member for Japan Council for Quality Health Care and Professor of the Division of Patient Safety Management- Kyushu University Hospital, Kyushu University Graduate School of Medicine. He currently is an ISQua Expert. He serves various such fields of patient safety, clinical research, etc. His main interest is to promote patient safety based on lessons learned from intramural and/or nationwide adverse event (AE) reporting system. He has been engaged in AE reporting system for approximately ten years in JQ and crafted dozens of quarterly reports and monthly alerts. 

 

講演資料
Presentation

ISQua Webinar_April 2017_Shin Ushiro