Responsibility for reporting patient death due to hospital error in Japan when an error occurred at a referring institution.

In Japan, physicians are required to report unexpected health care-associated patient deaths to the police. Patients needing to be transferred to another institution often have complex medical problems. If a medical error occurs, it may be either at the final or the referring institution. Some fear that liability will fall on the final institution regardless of where the error occurred or that the referring facility may oppose such reporting, leading to a failure to report to police or to recommend an autopsy. Little is known about the actual opinions of physicians and risk managers in this regard. The authors sent standardised, self-administered questionnaires to all hospitals in Japan that participate in the national general residency program. Most physicians and risk managers in Japan indicated that they would report a patient's death to the police where the patient has been transferred. Of those who indicated they would not report to the police, the majority still indicated they would recommend an autopsy

Attitudes toward clinical autopsy in unexpected patient deaths in Japan: a nation-wide survey of the general public and physicians.

CONTEXT: Autopsy is a useful tool for understanding the cause and manner of unexpected patient death. However, the attitudes of the general public and physicians in Japan about clinical autopsy are limited. OBJECTIVE: To describe the beliefs of the general public about whether autopsy should be performed and ascertain if they would actually request one given specific clinical situations where patient death occurred with the additional variable of medical error. To compare these attitudes with previously obtained attitudes of physicians practising at Japanese teaching hospitals. DESIGN, SETTING AND PARTICIPANTS: We conducted a cross-sectional study of the general public. We sent standardised questionnaires in 2010 to a randomly selected non-physician adult population using a survey company for participant selection. Respondents gave their opinions about the necessity of autopsy and how they might act given various clinical scenarios of patient death. We compared these results with those of a previous survey of Japanese physicians conducted in 2009. RESULTS: Of the 2300 eligible general adult population, 1575 (68.5%) responded. The majority of the general public indicated they believed an autopsy was necessary. However, in cases of unclear medical error or unclear cause and effect relationship of medical care and patient death, the general public were much less likely to indicate they would actually request an autopsy than were physicians (p<0.0001). Currently in Japan the debate about the role autopsy should play in the case of error related to death is underway. The results from this study will be important in informing related decisions.

An Exploratory Study on Information Manipulation by Doctors: Awareness, Actual State, and Ethical Tolerance.

(1) Background: To what extent is information manipulation by doctors acceptable? To answer this question, we conducted an exploratory study aimed at obtaining basic data on descriptive ethics for considering this issue. (2) Methods: A self-administered questionnaire survey was conducted on a large sample (n = 3305) of doctors. The participants were queried on (1) whether they consider that information manipulation is necessary (awareness), (2) whether they have actually manipulated information (actual state), and (3) their ethical tolerance. (3) Result: The response rate was 28.7%. Sixty percent of the doctors responded that information manipulation to avoid harm to patients is necessary (awareness), that they have actually manipulated information (actual state), and that information manipulation is ethically acceptable. (4) Conclusion: While the present survey was conducted among doctors in Japan, previous studies have reported similar findings in the United States and Europe. Based on our analysis, we hypothesize that a relationship of trust between patients and medical personnel is crucial and that information manipulation is not needed when such a relationship has been established.

Attitudes toward autopsy in unexpected death: a nationwide survey of physicians and risk managers in Japanese teaching hospitals.

CONTEXT: Autopsy is a useful tool for understanding the manner and cause of death in unexpected patient death. The information about the opinions of physicians and risk managers in Japan regarding autopsy is limited. OBJECTIVE: To describe and evaluate the opinions of physicians and risk managers at Japanese teaching hospitals regarding forensic autopsy. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional study of all residency programme directors and risk managers completing a survey in January 2009. Specific clinical scenarios where autopsy would be essential to determine whether medical error occurred and whether medical care contributed to the death of the patient were presented. Respondents gave their opinion regarding the necessity of autopsy and their beliefs about if they would actually recommend it. RESULTS: Of 1113 eligible physicians and 1113 eligible chief risk management officers, 466 physicians (41.9%) and 599 risk managers (53.8%) responded. The majority of physicians and risk managers reported they would recommend an autopsy in cases of unclear medical error or unclear cause and effect relationship of medical care and patient death; however, 10% or more of physicians and 25% or more of risk managers (depending on the situation) reported that they would not recommend an autopsy. Risk managers were less likely than physicians to recommend and believe that autopsy was necessary. CONCLUSIONS: The majority of physicians and risk managers in Japan would recommend autopsy and believe in its necessity in cases of unexpected patient death.

Why are autopsy rates low in Japan? Views of ordinary citizens and doctors in the case of unexpected patient death and medical error.

This article examines what could account for the low autopsy rate in Japan based on the findings from an anonymous, self-administered, structured questionnaire that was given to a sample population of the general public and physicians in Japan. The general public and physicians indicated that autopsy may not be carried out because: (1) conducting an autopsy might result in the accusation that patient death was caused by a medical error even when there was no error (50.4% vs. 13.1%, respectively), (2) suggesting an autopsy makes the families suspicious of a medical error even when there was none (61.0% vs. 19.1%, respectively), (3) families do not want the body to be damaged by autopsy (81.6% vs. 87.3%, respectively), and (4) families do not want to make the patient suffer any more in addition to what he/she has already endured (61.8% vs. 87.1%, respectively).

Patient safety education at Japanese medical schools: results of a nationwide survey.

BACKGROUND: Patient safety education, including error prevention strategies and management of adverse events, has become a topic of worldwide concern. The importance of the patient safety is also recognized in Japan following two serious medical accidents in 1999. Furthermore, educational curriculum guideline revisions in 2008 by relevant the Ministry of Education includes patient safety as part of the core medical curriculum. However, little is known about the patient safety education in Japanese medical schools partly because a comprehensive study has not yet been conducted in this field. Therefore, we have conducted a nationwide survey in order to clarify the current status of patient safety education at medical schools in Japan. RESULTS: Response rate was 60.0% (n = 48/80). Ninety-eight-percent of respondents (n = 47/48) reported integration of patient safety education into their curricula. Thirty-nine percent reported devoting less than five hours to the topic. All schools that teach patient safety reported use of lecture based teaching methods while few used alternative methods, such as role-playing or in-hospital training. Topics related to medical error theory and legal ramifications of error are widely taught while practical topics related to error analysis such as root cause analysis are less often covered. CONCLUSIONS: Based on responses to our survey, most Japanese medical schools have incorporated the topic of patient safety into their curricula. However, the number of hours devoted to the patient safety education is far from the sufficient level with forty percent of medical schools that devote five hours or less to it. In addition, most medical schools employ only the lecture based learning, lacking diversity in teaching methods. Although most medical schools cover basic error theory, error analysis is taught at fewer schools. We still need to make improvements to our medical safety curricula. We believe that this study has the implications for the rest of the world as a model of what is possible and a sounding board for what topics might be important.

Patient safety education at Japanese nursing schools: results of a nationwide survey.

BACKGROUND: Patient safety education is becoming of worldwide interest and concern in the field of healthcare, particularly in the field of nursing. However, as elsewhere, little is known about the extent to which nursing schools have adopted patient safety education into their curricula. We conducted a nationwide survey to characterize patient safety education at nursing schools in Japan. RESULTS: Response rate was 43% overall. Ninety percent of nursing schools have integrated the topic of patient safety education into their curricula. However, 30% reported devoting less than five hours to the topic. All schools use lecture based teaching methods while few used others, such as role playing. Topics related to medical error theory are widely taught, e.g. human factors and theories & models (Swiss Cheese Model, Heinrich's Law) while relatively few schools cover practical topics related to error analysis such as root cause analysis. CONCLUSIONS: Most nursing schools in Japan cover the topic of patient safety, but the number of hours devoted is modest and teaching methods are suboptimal. Even so, national inclusion of patient safety education is a worthy, achievable goal.

Attitudes regarding reporting healthcare-associated patient deaths to the police: A nationwide survey of physicians and RMs in Japanese teaching hospitals.

In Japan, healthcare professionals are required by Article 21 of the Medical Practitioner's Law to report "unnatural deaths" to the police in cases of healthcare-associated patient death. The attitudes of medical personnel at the forefront of clinical medicine regarding reporting have not been described. We investigate the attitudes of physicians and risk managers (RMs) regarding reporting to the police under different circumstances. We sent standardized questionnaires to all hospitals in Japan that participate in the National General Residency Program. We asked physicians and RMs to indicate if they would report to the police or not under scenarios including cases where medical error is present, uncertain, or absent. We also asked if they would report when medical error had occurred and the cause-of-death was directly related, possibly related, or unrelated. We found most physicians believe they would report to the police if medical error clearly caused patient death. We found most RMs believe they would advise physicians to report given the same situation. Less but still a large number of participants favor reporting even when cause-of-death is not clearly related to medical care provided. This tendency persisted even when given a scenario where the hospital director opposed the decision to report.

The acceptability of the decision to withdraw life-sustaining treatment based on the living will and substituted judgements involving decision--the tendency of judiciary decisions and guidelines in Japan.

Recently in Japan, the topic of withdrawing life support is becoming increasingly urgent. The issue of living wills and surrogate decision makers in this process has received little attention. The purpose of this study is to examine recent judiciary decisions in Japan (criminal judgements) and recent guidelines regarding the decision to withdraw life-sustaining treatment based on the living will or surrogate decisions by the patient's family members. We found that most court rulings and all guidelines support withdrawal of life support based on patient wishes stated in a living will. On the other hand, only one judiciary decision supports the use of surrogate wishes in the decision to withdraw support, and the issue of surrogates was not clearly addressed in recent guidelines.