ENGLISH

Outline

The Japan Council for Quality Health Care (JQ) 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 JQ has been actively engaged in the said activities.

The JQ 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 JQ 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 JQ's website. The JQ would like to thank all cooperating medical institutions and relevant parties for reporting near-miss incidents and adverse events for the project.

Annual report

Project to Collect Medical Near-miss/Adverse Event Information 2022 Annual Report
Project to Collect Medical Near-miss/Adverse Event Information 2021 Annual Report
Project to Collect Medical Near-miss/Adverse Event Information 2020 Annual Report
Project to Collect Medical Near-miss/Adverse Event Information 2019 Annual Report
Project to Collect Medical Near-miss/Adverse Event Information 2018 Annual Report
Project to Collect Medical Near-miss/Adverse Event Information 2017 Annual Report
Project to Collect Medical Near-miss/Adverse Event Information 2016 Annual Report
Project to Collect Medical Near-miss/Adverse Event Information 2015 Annual Report
Project to Collect Medical Near-miss/Adverse Event Information 2014 Annual Report
Project to Collect Medical Near-Miss/Adverse Event Information 2013 Annual Report
Project to Collect Medical Near-Miss/Adverse Event Information 2012 Annual Report
Project to Collect Medical Near-Miss/Adverse Event Information 2011 Annual Report
Project to Collect Medical Near-Miss/Adverse Event Information 2010 Annual Report
Project to Collect Medical Near-Miss/Adverse Event Information 2009 Annual Report
Project to Collect Medical Near-Miss/Adverse Event Information 2008 Annual Report
Project to Collect Medical Near-Miss/Adverse Event Information 2007 Annual Report
Project to Collect Medical Near-Miss/Adverse Event Information 2006 Annual Report
Project to Collect Medical Near-Miss/Adverse Event Information 2005 Annual Report

Medical Safety Information

No.203:Extravascular Leakage in Pediatric Patients (1st Follow-up Report)
No.202:Failure to Open the Central Seal of a Dual Chamber Infusion Bag
No.201:Wrong Unit Selected on Syringe Pump
No.200:Burn Caused by Hot Water Used to Prevent Laparoscopic Lens Fogging
No.199:Medical Safety Information Highlightedin Quarterly Reports in 2022
No.198:Magnetic Material (e.g. Metal Products) Taken in the MRI Room (2nd Follow-up Report)
No.197:Forgetting to Switch on the Bed Leaving Sensor
No.196:Medical Safety Information Released in 2022
No.195:Examination/Procedure Conducted on Wrong Patient Due to Failure to Carry out Checks
No.194:Forgetting to Reconnect Ventilator Circuit Tubing Due to Use of a Test Lung
No.193:Wrong Drug Administration Route (1st Follow-up Report)
No.192:Pressure Ulcers Caused by Medical Devices
No.191:Local Injection of High-Concentration Adrenaline Due to Container Mix-Up
No.190:Selection of Wrong Connection for Indwelling Bladder Catheter
No.189:Burn Caused by a Hot Towel
No.188:Fitting of Elastic Stockings to Patients with Arteriosclerosis Obliterans of the Lower Limbs
No.187:Medical Safety Information Highlighted in Quarterly Reports in 2021
No.186:Failure to Check Blood Test Results before Administering Anticancer Drugs
No.185:Use of a Used Endoscope on Another Patient
No.184:Medical Safety Information Released in 2021
No.183:Confusion between Product Volume and Active Ingredient Dosage (1st Follow-up Report)
No.182:Drug Mix-up between Serenace Injection and Silece
No.181:Resected Organ/Tissue Remaining after Performing Laparoscopic Surgery
No.180:Incorrect Prescription of Meylon Injection 250 mL Preparation
No.179:Contamination with Another Patient’s Pathology Test Specimen
No.178:Burn while Bathing a Newborn or Infant
No.177:Accidental Ingestion of PTP Sheets(2nd Follow-up Report)
No.177 Attachment: For Users of Oral Medication
No.176:Disconnection of Ventilator Circuit Tubing
No.175:Medical Safety Information Highlighted in Quarterly Reports in 2020
No.174:Failure to Inject Enteral Nutrient after Administering Insulin
No.173:Tenfold Error in Flow Rate of Infusion Pump, etc.
No.172:Medical Safety Information Released in 2020
No.171:Reactivation of Hepatitis B Due to Immunosuppression/Chemotherapy
No.170:Provision of Unsuitable Food to a Patient with Impaired Chewing/Swallowing Function
No.169:Omission from Prescription/Order When Continuing Prescription for Current Medicines Brought in at Hospitalization
No.168:Failure to Check Oxygen Tank Valve Was Open
No.167:Bone Marrow Suppression Due to Antirheumatic (Methotrexate) Overdose (2nd Follow-up Report)
No.166:Surgical Procedure Other Than Patient-Consented Procedure Carried Out
No.165:Alert Failure Resulting in Administration of a Drug to a Patient Allergic to It
No.164:Central Venous Catheter Guide Wire Left Behind
No.163:Medical Safety Information Highlighted in Quarterly Reports in 2019
No.162:Falls When Transferring to a Bed
No.161:Burns Caused by a Pulse Oximeter Probe
No.160:Medical Safety Information Released in 2019
No.159:Misconnection Causing Obstructed Exhalation in Patients with an Endotracheal/Tracheostomy Tube
No.158:Administration of a Sustained-Release Preparation in Ground-Up Form
No.157:Rectal Injury Due to Glycerin Enema Administered in a Standing Position
No.156:Incorrect Administration of Injection Drug Used for Sedation
No.155:Falls from a Pediatric Bed
No.154:Patient Mix-up When Using Electronic Medical Records
No.153:Gauze Remaining After Surgery (2)—Checking the X-ray Image—
No.152:Gauze Remaining After Surgery (1)—Gauze Count—
No.151:Medical Safety Information Highlighted in Quarterly Reports in 2018
No.150:Forgetting to Check the Pathologic Diagnosis Report—Upper Gastrointestinal Endoscopy—
No.149:Operation/Examination Postponed Due to Delays in Stopping Drugs
No.148:Medical Safety Information released in 2018
No.147:Injury from a Wheelchair Footrest
No.146:Inadequate checks of Oxygen Remaining (1st Follow-up Report)
No.145:Administration of the Usual Dosage of Drugs for Patients with Impaired Renal Function
No.144:Failure to Submit a Pathology Specimen
No.143:Error When Refilling a Prescription Due to Failure to Revise Prescription Details
No.142:Urethral Damage Caused by an Indwelling Bladder Catheter (1st Follow-up Report)
No.141:Falls from an Examination Table
No.140:Administration of an Antineoplastic Agent in Excess of the Total Dosage Limit
No.139:Medical Safety Information released from 2014 to 2016
No.138:Inadequate Checks Concerning Diagnostic Imaging Reports (1st Follow-up Report)
No.137:Burns When Using a Heat Pack
No.136:Medical Safety Information released in 2017
No.135:Failure to Release Standby Mode When Resuming Ventilation (1st Follow-up Report)
No.134:Erroneous Administration of Disinfectant in the Sterilized Area
No.133:Chest Drain Left Open to Air
No.132:Patient Falls While Using the Overbed Table for Support
No.131:Misunderstanding of Insulin Units(1st Follow-up Report)
No.130:Air Embolism Due to a Central Venous Line Left Open
No.129:Contraindicated Combined Administration of Drugs (1st Follow-up Report)
No.128:Wrong Site Surgery(Right/Left)—Neurosurgical Procedures—
No.127:Medical Safety Information released from 2013 to 2015
No.126:Blood Sample Taken from Limb During an Infusion in the Same Limb
No.125:Insufficient Understanding of Drugs to be Halted Pre-operatively
—Oral Contraceptives—
No.124:Medical Safety Information released in 2016
No.123:Film Dressing Affixed to Permanent Tracheostomy
No.122:Error in Measuring Body Weight Before Dialysis
No.121:Wrongly Inserted Nasogastric Feeding Tube
No.120:Administration of the Wrong Drug from a Syringe Not Labeled with the Drug Name
No.119:Incorrect Setting of Medication Quantity or Solution Volume on a Syringe Pump
No.118:Drug Mix-up Due to Similar Appearance
No.117:Inadequate Checks of Meal Type Information from Other Facilities
No.116:Patient Mix-up in Drug Administration
No.115:Medical Safety Information released from 2012 to 2014
No.114:Forgetting to Resume Anticoagulants/Antiplatelet Drugs
No.113:Air Embolism after Removal of a Central Venous Catheter
No.112:Medical Safety Information released in 2015
No.111:Delays in Urgent Contact Regarding Panic Values
No.110:Blood Transfusion to Wrong Patient (1st Follow-up Report)
No.109:Wrong Specimen Container When Taking Blood Samples
No.108:Incorrect Concentration of Adrenaline
No.107:Surgical Fire Due to Ignition of a Flammable Drug by an Electrosurgical Pencil
(1st Follow-up Report)
No.106:Wrongly Prepared Drug for a Pediatric Patient
No.105:Forgetting to Open/Close a T-shaped Stopcock
No.104:Wrong Weight When Prescribing an Antineoplastic Agent
No.103:Medical Safety Information released from 2011 to 2013
No.102:Misinterpretation of a Verbal Order
No.101:Wrong Drug Administration Route
No.100:Medical Safety Information released in 2014
No.99:Left-Right Mix-Up When Inserting a Thoracostomy Tube
No.98:Wrong Method of Administering a Potassium Preparation
No.97:Wrong Choice of Pneumococcal Vaccine Preparation
No.96:Insulin Pen Mix-up
No.95:Dead Battery in a Central Monitor Transmitter
No.94:Magnetic Material (e.g. Metal Products) Taken in the MRI Room (1st Follow-up Report)
No.93:Wrongly Registered Antineoplastic Drug Regimen
No.92:Forgetting to Connect Ventilator Hoses
No.91:Medical Safety Information released from 2006 to 2012
No.90:Catheter or Tube Erroneously Cut with Scissors
No.89:Syringe Pump Mix-up
No.88:Medical Safety Information released in 2013
No.87:Burns during a Foot Bath or Shower
No.86:Administration of Contraindicated Drug
No.85:Accidental Removal of a Drain/Tube during Transfer
No.84:Insufficient Confirmation of Incorrect Prescription
No.83:Failure to Reopen All Clamps on a Cerebrospinal Fluid Drainage Circuit
No.82:Accidental ingestion of PTP sheets (1st Follow-up Report)
No.81:Body Part Trapped in Gaps in Side Rails, etc. When Operating Beds
No.80:Urethral Damage Caused by an Indwelling Bladder Catheter
No.79:Medical Safety Information released from 2006 to 2011
No.78:Wrong Quantity Prescribed When Switching from Medicines Brought in at Hospitalization to Internal Prescriptions
No.77:Vasculitis due to administration of gabexate mesilate (1st Follow-up Report)
No.76:Medical Safety Information released in 2012
No.75:Total Dose Wrongly Entered as Flow Rate in Infusion Pump, etc.
No.74:Wrongly Assembled Manual Resuscitator
No.73:Patient Mix-up during Radiological Examinations
No.72:Misconnection of Drugs for Continuous Infusion into the Epidural Space
No.71:Forgetting to Check the Pathologic Diagnosis Report
No.70:Burns Caused by the Tip of a Light Source Cable during Surgery
No.69:Provision of Food to Which the Patient was Allergic
No.68:Drug mix-up (1st Follow-up Report)
No.67:Medical Safety Information released from 2006 to 2010
No.66:Misconception of insulin content (1st Follow-up Report)
No.65:Wrong Pick-up of Drug Set Out on the Emergency Cart
No.64:Medical Safety Information released in 2011
No.63:Inadequate Checks Concerning Diagnostic Imaging Reports
No.62:Insufficient Confirmation Concerning Medical Devices Implanted into the Patient's Body
No.61:Contraindicated Combined Administration of Drugs
No.60:Vaccination with an Immunization Vaccine Past its Expiry Date
No.59:Burns Due to Incorrect Handling of an Electrosurgical Pencil
No.58:Rupture of the subcutaneous port and catheter
No.57:Accidental ingestion of PTP sheets
No.56:Burns caused by a high-frequency electric current loop during MRI examination
No.55:Medical Safety Information released from 2006 to 2009
No.54:Accidental removal of the endotracheal/tracheostomy tube when changing positions
No.53:Specimen mix-up at pathological diagnosis
No.52:Medical Safety Information released in 2010
No.51:Insufficient knowledge of the administration status for warfarin potassium and blood coagulability
No.50:Wrong site surgery (right/left) (1st Follow-up Report)
No.49:Failure to implement measures to prevent mother-to-child transmission of Hepatitis B
No.48:Failure to check oxygen remaining
No.47:Mix-up of the tooth extraction site
No.46:Burn caused by a bed-bath towel
No.45:Bone marrow suppression due to antirheumatic (Methotrexate) overdose
(1st Follow-up Report)
No.44:Connection of medical and electrical devices exceeding the electrical capacity of the outlet (rated current)
No.43:Medical Safety Information released from 2006 to 2008
No.42:Reception error of patient's ECG waveform in central monitoring system
No.41:Drug administered at a wrong dose level due to discrepancy in interpretation of prescription (1st follow-up Report)
No.40:Medical Safety Information released in 2009
No.39:Insufficient confirmation of medicines brought in at hospitalization
No.38:Wrong pick-up of syringe containing drug in sterilized area
No.37:Failure to release "standby" mode when resuming ventilation
No.36:Insufficient confirmation of relevant information at the time of tooth extraction
No.35:Respiratory suppression due to Remifentanil (Ultiva) remained in intravenous infusion line
No.34:Surgical fire due to ignition of a flammable drug by an electrosurgical pencil
No.33:Extravascular leakage of gabexate mesilate
No.32:Insufficient closure of water trap cup
No.31:Medical Safety Information released from 2006 to 2007
No.30:Administration of allergic drug to patient with previous known allergy history
No.29:Administration of 10 times proper dosage to pediatric patients
No.28:Medical Safety Information released in 2008
No.27:Wrong dosage of drug due to incomplete verbal instruction
No.26:Wrong application of reagent strips not designated for a specific blood glucose testing devices
No.25:Patient mix-up during medical examination
No.24:Tubing misconnection of ventilator circuit
No.23:Wrong input of units on computerized prescription order entry system
No.22:Wrong prescription related to chemotherapy protocol
No.21:Caution to ensure proper usage of blood glucose testing devices
No.20:Failure to transmit an alteration of instruction
No.19:Use of unsterile medical supplies
No.18:Drug administered at a wrong dose level due to discrepancy in interpretation of the prescription
No.17:Burn during use of a hot water bottle
No.16:Medical Safety Information released in 2007
No.15:Wrong pick-up of syringe containing drug
No.14:Tubing (catheter/drain) misconnections
No.13:Failure to check of infusion pump flow
No.12:Collision during patient transfer
No.11:Blood transfusion to wrong patient
No.10:Magnetic material(e.g. metal products)taken in the MRI room
No.9 :Confusion between total product amount and content of active ingredient
No.8 :Wrong site surgery (right/left)
No.7 :Extravascular leakage in pediatric patients
No.6 :Misconception of insulin unit
No.5 :Burn during assisted bathing
No.4 :Drug mix-up
No.3 :Rectal perforation associated with glycerin enema
No.2 :Bone marrow suppression due to antirheumatic (methotrexate) overdose
No.1 :Misconception of insulin content


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