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Project to Collect Medical Near-Miss/Adverse Event Infomation


T.Outline

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.



U.Project Detail

Annual report.


 Project to Collect Medical Near-Miss/Adverse Event Information 2012 Annual Report  download

 Project to Collect Medical Near-Miss/Adverse Event Information 2011 Annual Report  download

 Project to Collect Medical Near-Miss/Adverse Event Information 2010 Annual Report  download

 Project to Collect Medical Near-Miss/Adverse Event Information 2009 Annual Report  download

 Project to Collect Medical Near-Miss/Adverse Event Information 2008 Annual Report  download

 Project to Collect Medical Near-Miss/Adverse Event Information 2007 Annual Report  download

 Project to Collect Medical Near-Miss/Adverse Event Information 2006 Annual Report  download

 Project to Collect Medical Near-Miss/Adverse Event Information 2005 Annual Report  download


Medical Safety Information


 No.83: Failure to Reopen All Clamps on a Cerebrospinal Fluid Drainage Circuit  download

 No.82: Accidental ingestion of PTP sheets (1st Follow-up Report)  download

 No.81: Body Part Trapped in Gaps in Side Rails, etc. When Operating Beds  download

 No.80: Urethral Damage Caused by an Indwelling Bladder Catheter  download

 No.79: Medical Safety Information released from 2006 to 2011  download

 No.78: Wrong Quantity Prescribed When Switching from Medicines Brought in at Hospitalization to Internal Prescriptions  download

 No.77: Vasculitis due to administration of gabexate mesilate (1st Follow-up Report)  download

 No.76: Medical Safety Information released in 2012  download

 No.75: Total Dose Wrongly Entered as Flow Rate in Infusion Pump, etc.  download

 No.74: Wrongly Assembled Manual Resuscitator  download

 No.73: Patient Mix-up during Radiological Examinations  download

 No.72: Misconnection of Drugs for Continuous Infusion into the Epidural Space  download

 No.71: Forgetting to Check the Pathologic Diagnosis Report  download

 No.70: Burns Caused by the Tip of a Light Source Cable during Surgery  download

 No.69: Provision of Food to Which the Patient was Allergic  download

 No.68: Drug mix-up (1st Follow-up Report)  download

 No.67: Medical Safety Information released from 2006 to 2010  download

 No.66: Misconception of insulin content (1st Follow-up Report)  download

 No.65: Wrong Pick-up of Drug Set Out on the Emergency Cart  download

 No.64: Medical Safety Information released in 2011  download

 No.63: Inadequate Checks Concerning Diagnostic Imaging Reports  download

 No.62: Insufficient Confirmation Concerning Medical Devices Implanted into the Patient's Body  download

 No.61: Contraindicated Combined Administration of Drugs  download

 No.60: Vaccination with an Immunization Vaccine Past its Expiry Date  download

 No.59: Burns Due to Incorrect Handling of an Electrosurgical Pencil  download

 No.58: Rupture of the subcutaneous port and catheter  download

 No.57: Accidental ingestion of PTP sheets  download

 No.56: Burns caused by a high-frequencyelectric current loop during MRI examination  download

 No.55: Medical Safety Information released from 2006 to 2009  download

 No.54: Accidental removal of the endotracheal/tracheostomy tube when changing positions  download

 No.53: Specimen mix-up at pathological diagnosis  download

 No.52: Medical Safety Information released in 2010  download

 No.51: Insufficient knowledge of the administration status for warfarin potassium and blood coagulability  download

 No.50: Wrong site surgery (right/left) (1st Follow-up Report)  download

 No.49: Failure to implement measures to preventmother-to-child transmission of Hepatitis B  download

 No.48: Failure to check oxygen remaining  download

 No.47: Mix-up of the tooth extraction site  download

 No.46: Burn caused by a bed-bath towel  download

 No.45: Bone marrow suppression due to antirheumatic (Methotrexate) overdose (1st Follow-up Report)  download

 No.44: Connection of medical and electrical devices exceeding the electrical capacity of the outlet (rated current)  download

 No.43: Medical Safety Information released from 2006 to 2008  download

 No.42: Reception error of patient's ECG waveform in central monitoring system  download

 No.41: Drug administered at a wrong dose level due to discrepancy in interpretation of prescription (1st follow-up Report)  download

 No.40: Medical Safety Information released in 2009  download

 No.39: Insufficient confirmation of medicines brought in at hospitalization  download

 No.38: Wrong pick-up of syringe containing drug in sterilized area  download

 No.37: Failure to release "standby" mode when resuming ventilation  download

 No.36: Insufficient confirmation of relevant information at the time of tooth extraction  download

 No.35: Respiratory deppression due to Remifentanil (Ultiva) remained in intravenous infusion line  download

 No.34: Surgical fire due to the flammable by electrocautery  download

 No.33: Extravascular leakage of gabexate mesilate  download

 No.32: Insufficient closure of water trap cup  download

 No.31: Medical Safety Information released from 2006 to 2007  download

 No.30: Administration of allergic drug to patient with previous known allergy history  download

 No.29: Administration of 10 times proper dosage to pediatric patients  download

 No.28: Medical Safety Information released in 2008  download

 No.27: Wrong dosage of drug due to incomplete verbal instruction  download

 No.26: Wrong application of reagent strips not designated for a specific blood glucose testing devices  download

 No.25: Patient mix-up during medical examination  download

 No.24: Tubing misconnection of ventilator circuit  download

 No.23: Wrong input of units on computerized prescription order entry system  download

 No.22: Wrong prescription related to chemotherapy protocol  download

 No.21: Caution to ensure proper usage of blood glucose testing devices  download

 No.20: Failure to transmit an alteration of instruction  download

 No.19: Use of unsterile medical supplies  download

 No.18: Drug administered at a wrong dose level due to discrepancy in interpretation of the prescription  download

 No.17: Burn during use of a hot water bottle  download

 No.16: Medical Safety Information released in 2007  download

 No.15: Wrong pick-up of syringe containing drug  download

 No.14: Tubing (catheter/drain) misconnections  download

 No.13: Failure to check of infusion pump flow  download

 No.12: Collision during patient transfer  download

 No.11: Blood transfusion to wrong patient  download

 No.10: Magnetic material(e.g. metal products)taken in the MRI room  download

 No.9 : Confusion between total product amount and content of active ingredient  download

 No.8 : Wrong site surgery (right/left)  download

 No.7 : Transfusion leakage in pediatric patients  download

 No.6 : Misconception of insulin unit  download

 No.5 : Burn during assisted bathing  download

 No.4 : Drug mix-up  download

 No.3 : Rectal perforation associated with glycerin enema  download

 No.2 : Bone marrow suppression due to antirheumatic (methotrexate) overdose  download

 No.1 : Misconception of insulin content  download

  Other Medical Safety Information's are available only in Japanese → Click here