Incident Reporting Analysis and Building the Culture of Safety
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Abstract
JQ Japan, or the Council for Quality Healthcare, was established in 1995 with a primary focus on hospital accreditation. It operates reporting and learning systems for adverse events and near-miss events, overseen by a steering committee with experts and patient representatives. They also provide a unique reporting and learning system for brain-damaged babies, offering monetary compensation to affected families. The Japan Council for Quality Health Care (JCQHC) produces quarterly and annual reports with over 100 tables, publicly available on their website. They also issue monthly alerts distributed to hospitals and clinics in Japan and globally through the Canadian project Global Patient Safety Alerts. The JCQHC’s adverse event database allows searching for specific events based on keywords or types of adverse events.
Introduction
JQ Japan, also known as the Council for Quality Healthcare, was founded in 1995 with a focus on hospital accreditation. Under the leadership of Dr. Hirobimi Kawakita, they expanded their scope to include reporting and learning systems for medical institutions and community pharmacies. Funding comes from various sources, including the Japan Medical Association and the Ministry of Health, Labour, and Welfare. JQ Japan collaborates with international organizations, aiming to enhance global partnerships.
The launch of national reporting on the learning system in Japan was driven by several devastating medical malpractice cases, which highlighted the need for patient safety measures. The Ministry of Health implemented a comprehensive patient safety policy, leading to reporting systems at both hospital and national levels.
The Six Dimensions of Health
Initially, medical institutions were hesitant to report accidents to the government, but with revised ordinances, the reporting system was transferred to the JQ organization in 2004. Subsequently, in 2006, all medical institutions were mandated to have internal reporting and learning systems, resulting in the establishment of two reporting levels.
Currently, JQ operates multiple reporting and learning systems, with specific hospital types, including university and national hospitals, required to report adverse events as per government ordinances.
They operate the following types of reporting and learning systems:
- Medical institutions such as hospitals and clinics.
- Community pharmacies.
- Collecting data related to profound cerebral palsy, meaning babies born with brain damage during delivery.
- It is operated by a separate organization and is limited to collecting data on fatal and accidental deaths.
Nationwide adverse event reporting/learning
JQ Japan uses a web-based reporting system to collect adverse events and near-miss incidents, overseen by a steering committee with experts and patient representatives. The data is analyzed and presented as annual, quarterly, and monthly reports, which are publicly available for transparency. On-site visits to medical institutions offer deeper insights. They also provide training courses and maintain a database of reported cases. The system is significant in Japan due to its super-aging population.
The unique reporting and learning system compensates families of brain-damaged babies with cerebral palsy caused during delivery, leading to a decrease in lawsuits. The system was launched in 2004 and is a crucial part of global patient safety efforts.
Currently, 274 hospitals are mandated to report adverse events, while 820 participate voluntarily. For near-miss events, 1256 medical institutions report, with some overlap, making a total of approximately 1500 participants, covering 17 to 18% of hospitals in Japan.
Previously, there was a steady rise shown in external reporting, and there are some possible reasons for this trend. These are:
- The no-blame culture and anonymity provided by JQ
- There has been immense pressure on medical institutions to register
- There is enhanced transparency and accountability
These are the primary reasons for the successful operation of the reporting and learning system.
In the neonatal intensive care unit (NICU), a 24-time overdose of heparin solution occurred due to a prescribing error.
The physician mistakenly prescribed 100 units per kilogram per hour instead of per day. The prescription was handwritten and dispensed without inspection by a non-professional nurse during a night shift. The overdose was detected only when the baby showed bleeding and fluid retention. The case was analyzed thematically, and measures to prevent similar incidents are presented in monthly reports. Lack of pharmacist presence, critical flow rate information missing in the ordering system, and insufficient inspection contributed to the error.
Collaboration for National Group: Japan National University Hospital Alliance for Patient Safety (JANUHA-PS)
In 2012, JAPAN Patient Safety collaborated with the Japan National University Hospital Alliance for Patient Safety. They conducted thematic analyses on various topics, including the failure to confirm CT and MRI reports. One highlighted case involved a patient with an abdominal aortic aneurysm who developed lung cancer after a suspicious lesion was overlooked in a previous radiologist’s report. Similar cases were reported in the media, prompting a 2017 questionnaire survey. The survey revealed that only 58% of university hospitals had an electronic notification system for imaging reports. Consequently, the alliance swiftly implemented a notification system from 2018 to 2020 to reduce potential errors.
Understanding the importance of monthly alerts through various channels
The monthly alerts are distributed to Japanese hospitals, with 70% receiving them via fax and the rest through other channels. These alerts are widely recognized and used throughout Japan. An English version is also produced and distributed globally through the Canadian project Global Patient Safety Alerts. The Dublin Collaboration Center in Italy aims to enhance collaboration with the Canadian Patient Safety Institute, expanding the project’s reach worldwide. The reporting and learning systems also have English pages, accessible by searching for “Japan Council for Quality Health Care” and “Project to Collect Adverse Event Information” on Google. These pages include the annual report and medical monthly alerts.
The adverse event database allows for refined searches using keywords or selecting specific adverse event types, providing relevant results. For instance, entering “dialysis” retrieves 706 related cases for download. Both coding and text data are available in Microsoft Excel for practical use. Collaboration with AI experts aims to develop a system for AI analysis of reported cases.
Training text with annotated meanings has been produced, focusing on medication incident reports. The project is led by a female researcher from Hong Kong, in collaboration with a university and a private company. Distinguishing intended and delivered drugs to patients is the team’s recent focus.
The study examined adverse events and near misses in laparoscopic and thoracoscopic surgeries. Researchers analyzed 746 events from the Japan Council for Quality Health Care database, finding 582 related to laparoscopic surgeries, 159 to thoracoscopic surgeries, and 5 to combined procedures. Common events included organ injury, foreign body retention, equipment failure, massive bleeding, misperception of anatomy, and vascular injury. Significant differences were observed between laparoscopic and thoracoscopic groups for certain events. Among 56 patient-death reports, 132 adverse events were identified, with bleeding more prevalent in thoracoscopic surgeries. The study emphasizes recognizing recurrent incidents and suggests specialized checklists to prevent foreign body retention and equipment malfunctions.[1]Abe, T., Murai, S., Nasuhara, Y., & Shinohara, N. (2019). Characteristics of medical adverse events/near misses associated with laparoscopic/thoracoscopic surgery: a retrospective study based on the Japanese National Database of Medical Adverse Events. Journal of Patient Safety, 15(4), 343.
Adverse event database
Conclusion
JQ operates several reporting and learning systems for medical institutions, community pharmacies, and cases of brain-damaged babies, and provides a database of reported cases and training courses. The organization collaborates with other hospitals and institutions to improve patient safety and implements preventive measures to minimize adverse events. The English version of their reports and alerts is distributed globally through the Canadian Patient Safety Institute and the Dublin Collaboration Center in Italy. Overall, JQ is committed to enhancing patient safety and sharing its findings with the healthcare community both domestically and internationally, resulting in a significant decrease in lawsuits.
JQ Japan, or the Council for Quality Healthcare, is an organization in Japan established in 1995 with a focus on hospital accreditation. Over time, they expanded their scope to include reporting on the learning system and other initiatives. They receive funding from various sources, including the Japan Medical Association and the Ministry of Health, Labour, and Welfare.
