|SHIN USHIRO||Last modified date：2020.07.23|
Professor / Kyushu University Hospital
|SHIN USHIRO||Last modified date：2020.07.23|
|1.||Measures for patient safety promotion at institutional level was presented..|
|2.||The history of patient safety measures and projects in Japan was described..|
|3.||Novel system in University hospital to review novel procedure ans surgery was described..|
|4.||Description on activities of anesthesiologists who have had interest in patient safety..|
|5.||Description on activities of anesthesiologists who have had interest in patient safety..|
|6.||Description on activities of anesthesiologists who have had interest in patient safety..|
|7.||Description on activities of anesthesiologists who have had interest in patient safety..|
|8.||Description on Quality and Safety in medicine in terms of history, current initiatives and international trend..|
|9.||Description on Quality and Safety in medicine in terms of history, current initiatives and international trend..|
|10.||Description on Quality and Safety in medicine in terms of history, current initiatives and international trend..|
|11.||Intoroduction of incident reporting and learning system of University hospital in which serioue adverse ebnents are reported and internal investigation and prevention system.
Introduction of a unique no-fault based system for cerebral palsy and its achievement.
The lecture also touched ont the experience by NHS, UK, of serious medical accidents which took place in 1990's and patient safety promotion in response to the incident in the years that followed..
|12.||Intoroduction of incident reporting and learning system of University hospital in which serioue adverse ebnents are reported and internal investigation and prevention system.
Intreoduction of a unique no-fault based system for cerebral palsy and its achievement.
|13.||Nationwide adverse event reporting and learning system and unique no-fault compensation system for cerebral palsy case were introduced..|
|14.||Intoroduction of incident reporting and learning system of University hospital in which serioue adverse ebnents are reportted and internal investigation and prevention system.
The lecture also included topic on the relation between resident's working hours and patient safety..
|15.||Intoroduction of incident reporting and learning system of University hospital in which serioue adverse ebnents are reportted and internal investigation and prevention system..|
|16.||Intoroduction of incident reporting and learning system of University hospital in which serioue adverse ebnents are reportted and internal distribution of preventative measures..|
|17.||Introduction of the adverse event reporting and learning system on national scare and itsu achievement on patient safety promotion in Japan..|
|18.||SHIN USHIRO, Country Experiences/Initiatives: National, Subnational or Institutional Patient Safety Incident Reporting and Learning SystemA report from Japan, WHO Inter-regional Consultation Conference in Colombo, Sri Lanka , 2016.03.|
|19.||SHIN USHIRO, Reporting and Learning Systems- A Case for ProgressNationwide adverse event reporting system and relevant systems, patient safety infrastructures, in Japan, Inter-Regional Technical Consultation on Best Practices in Patient Safety and Quality of Care, 2016.02.|
|20.||SHIN USHIRO, Application of knowledge gained through adverse event reporting system and no-fault compensation/peer-review system to new peer-review system on clinical death case in Japan, 32nd International Conference of the International Society for Quality in Health Care,, 2015.10.|
|21.||SHIN USHIRO, The Status Quo of the Web-based Nationwide Adverse Event Reporting System in Japan, International Forum on Quality and Safety in Healthcar, 2015.09.|
|22.||SHIN USHIRO, A new peer-review system on clinically accidental death case in Japan “How does it relate to JQ’ projects on patient safety? ”
, Taichung Patient Safety Study Group, 2015.09, Japan Council for Quality Health Care (JQ) has carried nationwide adverse event reporting system and no-fault compensation/peer-review system for profound cerebral palsy. In those programs, adverse event is investigated, analyzed and eventually gives rise to a report on the individual case basis though the degree of detail and elaboration varies among reports. Thereafter, piles of those reports are subjects to compiling a report for prevention.
Through the years, JQ has built up knowledge to operate those systems and generate a preventive measures and educational materials for prevention of adverse event.
Along with the operation of those systems, Japan has faced another specific challenge which is how to investigate cause of accidental death case not only for relieving conflict between medical institution and bereaved family but for generating preventive measures and avoiding prosecution process. Trial project for studying feasibility of the new system specific to accidental death case funded by the ministry of health, labour and welfare in which clinical death case was investigated has been conducted by Japan Medical Safety Research Organization, a neutral third body like JQ, for nearly ten years. With the knowledge which has accumulated in the project, the Japanese government is planning to launch a new peer-review system on accidental patient death based on Health Service Law on October 1, 2015. 1300-2000 death cases are annually expected to be subjected to the new system.
According to the framework of the new system illustrated in the law, enforcement ordinance and notice, workflow of the system is described as follows. Accidental death case defied as “Medical accident” in the Health Service Law should be reported to the Japan Medical Safety Research Organization, a recently registered third body as an operating organization, thereafter, the in-house investigation is conducted. On completion of the investigation, the medical institution should explain the outcome of the investigation to bereaved family through verbal explanation and/or documentary explanation. The investigation report should be sent to the third body. The third body receives investigation reports from medical institutions all over Japan, create knowledge to spread to medical institutions for prevention by studying common nature of cause of similar cases.
The question of how to successfully operate the new system in terms of investigation and prevention can be answered on the basis of knowledge created by JQ's projects. With regard to the in-house investigation report, the law only describes that the medical institution should conduct investigation to elucidate cause of the case. There is neither standard form for the investigation report nor procedure which should be common among investigations.
Therefore, the idea of referring to the investigation report which has been compiled for seven years in the Japan obstetric compensation system could be effective for envisioning the standard report in terms of form and procedure to compile a report in the new system. The obstetric compensation system has an intensive peer review in which expert groups review and eventually compile a peer-review report of individual cases. Approximately seven hundred reports have been completed and delivered to both families and childbirth facilities so far.
Furthermore, the planned scheme for prevention in the new system is quite similar to the one carried out in the JQ's adverse event reporting system. Specifically, it is similar to collect cases, study common nature among similar cases, crafts and distributes written documents and alerts for the reference of medical professionals on the frontline of medicine.
The reporting system collected 3,194 accident and 29,736 incident reports in 2014 under the condition of anonymity from 1,399 medical institutions accounting for 16% of Japanese hospitals. JQ published annual/quarterly reports and monthly alerts as planned in 2014 for recurrence prevention. It should be stressed that web-based reporting and analyzing system developed in JQ has enabled to efficiently deal with a great number of cases reported from entire medical specialties.
The new peer-review system will begin on Oct 1. JQ’s adverse event reporting system and no-fault compensation/peer-review system has fostered two different methodologies to cover entire adverse event for prevention.
They surely provides with ideas which enable the new system to be operated efficiently and effectively.
In the lecture, the idea of how to introduce the knowledge fostered in those two projects to the new peer-review system, in other words, the plausible answer to the question “How does the new system relate to JQ's projects?” will be presented.