Professor Shin Ushiro is Executive Board Member – Japan Council for Quality Health Care (JQ) and Deputy Director and Professor of Patient Safety – Kyushu University Hospital.
A brief history of Japan’s patient safety journey
Around the year 2000, several devastating medical accidents took place in my country which were highlighted in the media:
- Patient X and patient Y were switched resulting in wrong surgery to heart and lung (1999).
- Disinfectant solution was wrongly injected to a patient immediately after surgery instead of anti-coagulant, leading to death (1999).
- The hospital staff mistakenly poured ethanol into a humidifying unit of a ventilator instead of distilled water resulting in the death of the patient (2000).
This led to the then Minister of Health, Labour and Welfare to issue an ‘urgent declaration’ on patient safety, which was an unusual response by the government to any issue. It was followed in 2002 by a comprehensive policy on patient safety. I often quote the declaration in my domestic lectures to students and medical staff so that they understand the frustration that arose in our society in the early 2000s.
Minister’s message on patient safety:
“Medical accidents take place frequently in recent months in such a way that there is not a single day in which people do not talk about medical accidents with profound worry. In a case, physician was arrested which is what we cannot tolerate.
“Medical care is inherently a system to safeguard people’s lives and health, however, frequent accident in medical care just greatly hampers people’s positive expectation and trust on the system.
“The Ministry of Health, Labour and Welfare (MHLW) has prioritized patient safety among agendas in healthcare and welfare and released “Comprehensive Policy on Patient Safety” in 2002 compiled in close cooperation with stakeholders. The MHLW has been engaged with patient safety ever since along with it. Although I acknowledge that medical professionals intensively engage with safe care on the frontline, I still worry about the situation just escalating in which people continue to lose trust on healthcare unless we stop the occurrence of sequential accidents as soon as possible.
“I sincerely request medical professionals that they make further effort in ensuring patient safety that brings sense of safety and trust to people who are or will be under healthcare.”
The Japan Council for Quality Health Care (JQ), in a joint response with the ministry, launched the national reporting and learning system in 2004. It has produced a variety of products as feedback, such as periodical reports including numerical and thematic analysis, monthly alerts, and a database of adverse events and near-misses. I would like to stress that feedback which people on healthcare frontlines see helpful is important to the sustainability of the system. It continues to develop and expand over time, including the introduction of a no-fault compensation system for birth injury due to poor quality maternal and neonatal care. You can read more about the development of our national reporting and learning system, and the no-fault compensation system in my next blog posts for HSSIB.
Similarities with other countries
I had wondered, as my experience on the no-fault compensation system developed, if birth injury due to poor quality maternal and neonatal care was on the agenda in other countries. This led me to England and Malaysia.
As you all know, it has been frequently reported in England that there might have been poor quality care in specific NHS hospital trusts, which was revealed through investigations conducted in response to the voices of families and experts. I was invited to the Select Committee on NHS Litigation Reform in January 2022, together with international experts from Sweden, New Zealand and the USA. I described the experience of the JQ’s system in anticipation of being of some help to further discussion on improving maternal and neonatal care in the NHS in England. The JQ’s experience was kindly included as one of the case studies in the annual report by the Institute for Healthcare Innovation, Imperial College London ‘Global Patient Safety Report 2023’.
Malaysia is another country that I have been working with on launching a similar system. I was invited by the Obstetrical and Gynaecological Society of Malaysia in 2019 to give a presentation on the JQ’s experience and subsequently given an opportunity to speak to the Minister of Health. The Minister’s instruction to government officials and experts enabled publication of a new system to address birth injury in which it provides no-fault compensation, investigation, and prevention.
I shared the experience in April 2024 on occasion of the 6th Global Ministerial Summit on Patient Safety held in Santiago, Chile. I made a presentation on the JQ’s system in ‘Expert Plenary: Balancing safety culture and patients' rights: legal aspects of patient safety’. I included in my presentation what I experienced in conversation and discussion with experts, lawmakers, and colleagues in England.
Through the discussions I had with international experts from these countries and beyond, I think it is important to share experiences including success and failure with each other to find solutions that fit the local context.
Future perspectives
The HSSIB kindly provides me with the opportunity to work with international experts on investigation through meetings of the International Patient Safety Organisations Network (IPSON) in which I have shared whatever I experienced in domestic and international occasions.
I have been impressed with surprise that Japan, England and other countries have developed similar systems for patient safety with ‘reporting and learning’ and ‘investigation’ as core principles, although the degree of advancement vary.
Penetration of the products produced in the systems, reporting from medical professionals and institutions without a sense of fear, hearing the voices of patients and families, application of artificial intelligence (AI) to analysis of adverse events, still lie ahead as shared agendas among members of IPSON. I anticipate synergistic advancement in days and years to come through the collaboration that HSSIB and IPSON provides.
