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



後 信
公益財団法人 日本医療機能評価機構 執行理事


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


Participant Feedback

平井 治
“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

安食 愛彦
“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


About the Webinar


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.

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


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. 



ISQua Webinar_April 2017_Shin Ushiro