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The contents will be regularly updated.

Last Update:2019年5月28日

INDEX

About Us

Mission

  We contribute to the assurance of safety and improvement of quality in medical care through the analysis and dissemination of findings useful for the establishment of appropriate measures for accident prevention by means of information collection, verification, investigation, and training activities for prevention of medical accidents stipulated in Article 6-10 of the Medical Care Act based on expertise, neutrality, fairness, and transparency. 


Date founded:
April 1, 2010

Chair:
Fumimaro Takaku

 

Message from the Chair

    The Medical Accidents Investigation System became effective in October 2015. The necessity of this system has been highlighted from the perspective of not only family members of those who lost their lives in unfortunate accidents of medical care, but also medical professionals and the society. However, the establishment of this system required adequate time.

 The causes of medical accidents that could occur in medical care, which continue to multiply, and become complex and subject to the aging society, involve various issues specific to medical care, including its uncertain nature and difficulty in establishing a system to prevent errors by individual persons. Under these circumstances, it gradually became clear that the perception that the basic idea of investigation in medical accidents is in determining where responsibility lies and punishing those responsible not only failed to clarify the essential cause but also failed to lead to learning from the accident and implementing measures to prevent similar accidents from occurring in the future. This was believed to be the reason why experience and time was required for the approval of this system. As a result, we may have been able to identify a new basic idea of investigation in medical accidents, which is to clarify the cause of the accident and to link the findings to the prevention of recurring accidents.

 The current revision of the Medical Care Act saw the establishment of the “Medical Accidents Investigation System,” which will be effective from October this year. Within this system, the Japan Medical Safety Research Organization was designated as the “Medical Accident Investigation and Support Center” by the Minister of Health, Labour and Welfare. It is the responsibility of all those involved in this system to ensure that it is implemented by focusing on investigating accidents in hospitals. The Japan Medical Safety Research Organization will make the best effort to appropriately implement and offer assurance of operations stipulated in the revised the Medical Care Act.

 We request your continued cooperation and guidance.                             

 October 2015       


 Fumimaro Takaku 
 Chairperson of the Board 
 Japan Medical Safety Research 
 Organization 

           

 
 
Address:

5F World Trading Center Bldg., 2-4-1 Hamamatsu-cho, Minato-ku, Tokyo 105-6105, Japan
Phone: +81-3-5401-3021
Fax: +81-3-5401-3022

ACCESS:

Direct access via Hamamatsucho Station in JR (Yamanote Line/Keihin Tohoku Line) and Tokyo Monorail 
Direct access from Daimon Station, Toei Subway (Asakusa Line/Oedo Line) (Exit B3)

History

 

Sep 2004   Nineteen academic societies affiliated with Japan Medical Association   
    issue a joint statement on “notifying treatment-related deaths of patients  
    —towards the foundation of neutral specialist institution.”  
       
Sep 2007   “Project for the Investigation and Analysis Models of Treatment-Related   
    Deaths,” supported by the Ministry of Health, Labour, and Welfare is   
    commenced, with the Japanese Society of Internal Medicine as the   
    operating entity.  
       
Apr 2010   The Japan Medical Safety Research Organization (JMSRO) is founded.         
    JMSRO takes over the “Project for the Investigation and Analysis Models of   
    Treatment-Related Deaths” supported by the Ministry of Health, Labour,   
    and Welfare from the Japanese Society of Internal Medicine.  
       
Jun 2014   A partial revision of the Medical Care Act results in the issue of “Medical   
    Accidents Investigation System,” which focuses on the investigation of   
    accidents in hospitals (effective as of October 1, 2015)  
       
Mar 2015   The “Project for the Investigation and Analysis Models of Treatment-  
    Related Deaths” supported by the Ministry of Health, Labour, and Welfare   
    is terminated.  
       
Aug 2015   The Ministry of Health, Labour, and Welfare designates JMSRO as a   
    “Medical Accident Investigation and Support Center” as a part of the   
    Medical Accidents Investigation System.  
       
Oct 2015   The “Medical Accidents Investigation System” comes into effect.  

Our Work

  We are in charge of the following operations stipulated in Article 6-16 of the Medical Care Act.

  1. We collect information on medical accidents from “medical accident reports” and “reports for the result of investigation on hospital accidents.”

  2. We organize and analyze information on medical accidents reported from medical institutions to investigate the measures to prevent the recurrence of such accidents, and return this to the society as an educational “proposal” of preventive measures for medical accidents.

  3. The Medical Accident Investigation and Support Center (hereinafter referred to as “the center”) will investigate reported cases of medical accidents stipulated in the Medical Care Act, if requested by the applicable medical institution or the family of the deceased, and report the results of the investigation to the medical institution or the family of the deceased.

  4. We conduct training based on knowledge and techniques related to the Medical Accidents Investigation System for the staff members of medical institutions and organizations supporting the investigations of medical accidents.

  5. We provide information and support required for consultation related to the investigation of medical accidents.

  6. We conduct other operations required to ensure safety in medical care.

Medical Accident Investigation System

To secure medical safety “Medical Accident Invesgaon System” in Japan

A new system related to medical accident was enforced in October 2015 under the Medical Care Act. The hospital, when “Medical Accident” occurs, conducts “In-Hospital Invesgaon”, and submits the report to “Medical Accident Invesgaon and Support Center [ISC]” A third party,  ISC who sorts and analyzes this report, draws up the prevenon of recurrence.

english-leaflet

①Decision of “Medical Accident” and report to ISC:

”Medical Accident“ is defined as  “Death or sllbirth which are caused or suspected to have been caused by   the care provided by employees of the medical instuons, and which are unforeseen by the administrator.” The administrator, if judged as “Medical Accident”, explains it to the bereaved family and reports it to ISC.

②“In-hospital Invesgaon”:

The hospital should conduct “In-hospital Invesgaon”, collecng and analyzing the data for the invesgaon of the causes of accident. If necessary, the hospital can ask a parcipaon of “Supporng Organizaon” for the    neutrality & fairness, specialty and transparency of the invesgaon.

③The Support organizaons and their support:

The organizaon consists of medical associaons, university hospitals and the medical sociees, etc. in each area. Assumed details of support are;

[Details of support]
・Consultaon on the decision of “Medical Accident”
・Advice on invesgaon method
・support on the procedures of “In-hospital Invesgaon”
・Support on autopsy and postmortem imaging
・Dispatch outside medical specialist for invesgaon
・Consult and advise on report preparaon

④Explanaon / submit of ” In-hospital Invesgaon” result:

When “In-hospital Invesgaon” completed, the hospital should explain the results to the bereaved family and report it to ISC. And ISC may confirm and inquire about the result as necessary, for the substanal  examinaon of prevenve measures.

⑤ISC invesgaon:

ISC (Medical Accident Invesgaon and Support Center) will perform invesgaon on the reported case, at the request of the concerned hospital or the bereaved family. The result is reported to both the hospital and the bereaved family.

⑥Awareness-raising on prevenon of recurrence:

Based on the collected informaon from the reports submied from the hospital, ISC provides awareness- raising informaon on prevenon of recurrence. The themes of measures were selected and examined as a whole,  not individual.

Documents

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To secure medical safety "Medical Accident Investigation System" in Japan

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“Medical Accidents Investigation System” in Japan

Recommendations

■Recommendations for the preventon of recurrence of medical accidents Number 1
Analysis of deaths related to the complications of "Central Venous Catheterization

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Analysis of deaths related to the complications of "Central Venous Catheterization"-First Report- 

■Recommendations for the prevention of recurrence of medical accidents Number 2
Analysis of deaths related to"Acute Pulmonary Thromboembolism"

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Analysis of deaths related to"Acute Pulmonary Thromboembolism"-First Report- 

Preventive measures against pulmonary thromboembolism

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Preventive measures against pulmonary thromboembolism

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