~Speakers~

Dr. Shin Ushiro, MD, Ph.D.

Professor and Director of Division of Patient Safety, Kyushu University Hospital

Speaker's Biography

Dr. Shin Ushiro works for the global community on quality and safety as a Board Member of the International Society for Quality Health Care (ISQua) and currently serves as an Executive Board Member of the Japan Council for Quality Health Care (JQ). He also responds to nationwide adverse event reporting & learning systems (RLS). The system has been successfully operated by valuing two principles as "Anonymity" and "Blame-free culture" and rendered a vital infrastructure for patient safety in Japan. RLS is an excellent idea that gave rise to similar systems that work for i) community pharmacy, ii) cerebral palsy (CP) in perinatal care, and iii) accidental death. The system for CP uniquely features no-fault-based compensation, investigation, and prevention. It has drawn incredible attention on scores of international occasions in which Dr. Shin delivered lectures on the system. With those achievements, Dr. Shin took Professor and Divisional Director of Patient Safety at Kyushu University.

Topic

Patient Safety and Candid Attitude to Patient/Family through Electric Incident Reporting System

Abstract

Japan underwent a desperate medical accident in the year around 2000, and those events ignited concern on patient safety in society. Therefore, the Japanese government released a national policy on patient safety promotion in 2002. It included the launch of adverse event reporting and learning systems at institutional and national levels. The system has been accepted over decades. JQ believes that the principles for successful operation such as i) blame-free culture and ii) anonymity were crucial elements to the system that is a vital infrastructure on patient safety in Japan. Among scores of events, those caused by electric health records (EHR) and events that could improve by introducing a preventive module to EHR. For instance, EHR adverse events in the ICU and other wards are often different because specifics on highly detailed and fine-tuning medication, procedures, etc., are preferred in the ICU. In contrast, comprehensive and well-balanced specifics welcome in other wards. It, accordingly, happened that overdose prescription alerted in most of the patient ward, while not warned of in ICU. Eventually, we went through overdose administration of the high-risk drug(s) to patients in ICU.

Another example is the cases that are dealt with equipping with new preventive modules. Over the last couple of years, media has highlighted a particular event that physicians overlooked CT/MRI imaging reports directly or indirectly suggesting cancer in the patent which later was dead due to delayed identification. A similar event took place in Kyushu University Hospital. It provoked a lawsuit that eventually came to an end in 2019 with the strict court ruling that charged huge damage payment on the hospital. In response to the event, KUH newly embedded a vigilance module in EHR to identify patients whose report was confirmed by a physician in charge. It currently works well, leaving fewer reports that is not confirmed. Another lesson of the case is the candid attitude of the patient/family. KUH have promoting swift identification of disputable event through the internal reporting system, prompt inquiry on the subject from clinical and legal viewpoints that leads to an explicit conclusion and candid account to patient/family with damage payment in need. It seems that we have more cases in recent years that bring to an early settlement out of the court.

It is a project at the institutional level hinted by JQ's reporting and learning system for cerebral palsy, distinctively featured by no-fault monetary compensation. The system has been incredibly successful and expanding, covering more CP cases. The system publishes an investigative report to childbirth facility/family, and Japan observed a rapid decline in the number of the lawsuit related to Obstetrics and Gynecology. It turned out that a similar project has also been promoted in the U.S. called "CANDOR" (Communication and Optimal Resolution) by AHRQ of the Department of Health and Human Services and Patient Safety Movement Foundation (PSMF). I hoped similar leadership would spread among patient safety communities on a global society basis.