The Japan Council for Quality Health Care (JCQHC) has been conducting various
activities, such as the Project to Collect Medical Near-Miss/Adverse Event Information and
the evaluation of medical services provided at hospitals, in order to maintain public
confidence in healthcare services and improve the quality of the services. In response to
rising awareness and expectations of the general public as well as medical institutions
concerning promotion of patient safety and medical adverse event prevention, the JCQHC
has been actively engaged in the said activities.
The JCQHC Division of Adverse Event Prevention has been undertaking the
Project to Collect Medical Near-Miss/Adverse Event Information to prevent medical adverse
events and to promote patient safety since 2004. As a neutral third-party organization, the
JCQHC has been publishing collected medical near-miss/adverse event information and the
analyses of data in the form of periodic reports, annual reports and monthly fax newsletters
for medical professionals, administrative organizations and the general public. The reports
can also be browsed on JCQHC's website. The JCQHC would like to thank all cooperating
medical institutions and relevant parties for reporting near-miss incidents and adverse
events for the project.
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Annual report.

| Project to Collect Medical Near-Miss/Adverse Event Information 2005 Annual Report |
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| Project to Collect Medical Near-Miss/Adverse Event Information 2006 Annual Report |
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| Project to Collect Medical Near-Miss/Adverse Event Information 2007 Annual Report |
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| Project to Collect Medical Near-Miss/Adverse Event Information 2008 Annual Report |
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| Project to Collect Medical Near-Miss/Adverse Event Information 2009 Annual Report |
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| Project to Collect Medical Near-Miss/Adverse Event Information 2010 Annual Report |
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Medical Safety Information

| No.1 : Misconception of insulin content |
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| No.2 : Bone marrow suppression due to antirheumatic (methotrexate) overdose |
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| No.3 : Rectal perforation associated with glycerin enema |
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| No.4 : Drug mix-up |
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| No.5 : Burn during assisted bathing |
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| No.6 : Misconception of insulin unit |
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| No.7 : Transfusion leakage in pediatric patients |
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| No.8 : Wrong site surgery (right/left) |
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| No.9 : Confusion between total product amount and content of active ingredient |
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| No.10: Magnetic material(e.g. metal products)taken in the MRI room |
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| No.11: Blood transfusion to wrong patient |
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| No.12: Collision during patient transfer |
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| No.13: Failure to check of infusion pump flow |
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| No.14: Tubing (catheter/drain) misconnections |
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| No.15: Wrong pick-up of syringe containing drug |
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| No.16: Medical Safety Information released in 2007 |
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| No.17: Burn during use of a hot water bottle |
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| No.18: Drug administered at a wrong dose level due to discrepancy in interpretation of the prescription |
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| No.19: Use of unsterile medical supplies |
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| No.20: Failure to transmit an alteration of instruction |
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| No.21: Caution to ensure proper usage of blood glucose testing devices |
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| No.22: Wrong prescription related to chemotherapy protocol |
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| No.23: Wrong input of units on computerized prescription order entry system |
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| No.24: Tubing misconnection of ventilator circuit |
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| No.25: Patient mix-up during medical examination |
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| No.26: Wrong application of reagent strips not designated for a specific blood glucose testing devices |
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| No.27: Wrong dosage of drug due to incomplete verbal instruction |
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| No.28: Medical Safety Information released in 2008 |
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| No.29: Administration of 10 times proper dosage to pediatric patients |
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| No.30: Administration of allergic drug to patient with previous known allergy history |
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| No.31: Medical Safety Information released from 2006 to 2007 |
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| No.32: Insufficient closure of water trap cup |
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| No.33: Extravascular leakage of gabexate mesilate |
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| No.34: Surgical fire due to the flammable by electrocautery |
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| No.35: Respiratory deppression due to Remifentanil (Ultiva) remained in intravenous infusion line |
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| No.36: Insufficient confirmation of relevant information at the time of tooth extraction |
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| No.37: Failure to resume ventilator without releasing "standby" mode |
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| No.38: Wrong pick-up of syringe containing drug in sterilized area |
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| No.39: Insufficient confirmation of medicines brought in at hospitalization |
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| No.40: Medical Safety Information released in 2009 |
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| No.41: Drug administered at a wrong dose level due to discrepancy in interpretation of prescription (2nd follow-up Report) |
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| No.42: Reception error of patient's ECG waveform in central monitoring system |
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| No.43: Medical Safety Information released from 2006 to 2008 |
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| No.44: Connection of medical and electrical devices exceeding the electrical capacity of the outlet (rated current) |
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| No.45: Bone marrow suppression due to antirheumatic (Methotrexate) overdose (2nd Follow-up Report) |
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| No.46: Burn caused by a bed-bath towel |
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| No.47: Mix-up of the tooth extraction site |
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| No.48: Failure to check oxygen remaining |
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| No.49: Failure to implement measures to preventmother-to-child transmission of Hepatitis B |
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| No.50: Wrong site surgery (right/left)(2nd Follow-up Report) |
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| No.51: Insufficient knowledge of the administration status for warfarin potassium and blood coagulability |
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| No.52: Medical Safety Information released in 2010 |
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| No.53: Specimen mix-up at pathological diagnosis |
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| No.54: Accidental removal of the endotracheal/tracheostomy tube when changing positions |
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| No.55: Medical Safety Information released from 2006 to 2009 |
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| No.56: Burns caused by a high-frequencyelectric current loop during MRI examination |
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| No.57: Accidental ingestion of PTP sheets |
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| No.58: Rupture of the subcutaneous port and catheter |
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| No.59: Burns Due to Incorrect Handling of an Electrosurgical Pencil |
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Other Medical Safety Information's are available only in Japanese → Click here
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