Nursing and patient safety
in Japan
2. Nursing and patient safety

Japanese Nursing Association

<In this series>
1. Patient safety in Japan
http://www.nurse.or.jp/jna/english/pdf/safety-01.pdf

2. Nursing and patient safety
3. Japanese Nursing Associationin action (to be issued soon)

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Terminology• Medical Safety: The term “Medical Safety” is used in Japan in the textof the Medical Care Act as well as in various guidelines of the Ministryof Health, Labour and Welfare (MHLW).
However, a clear definition of “Medical Safety” has not been
published.
In 2002, the Medical Safety Management Council of the MHLW
published a report titled, “Comprehensive Management for Medical
Safety Promotion– for the Prevention of Medical Accidents,” in which
the view is expressed that embracing patients’ safety as the highest
priority will nurture a “Safety Culture” as the background for the safe
provision of healthcare. This view has been maintained in a 2005
MHLW report titled, “On Future Medical Safety Management.”
At the same time the term, “Patient Safety,” which is often used
overseas, is also used in Japan.
• Patient Safety: The WHO defines Patient Safety as, “… reducing therisk of unnecessary harm associated with healthcare to an acceptable
minimum…”(WHO International Classification for Patient Safety, World Health Organization 2009, Geneva;
http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf (Accessed on July 8, 2015))• Medical Accidents: This term refers to all accidents that occur
anywhere and involve healthcare, and that result in physical injury or
death, including cases in which healthcare professionals are the victim,
as well as falls in corridors. (“Comprehensive Management for
Medical Safety Promotion,” a report by the Medical Safety
Management Council, MHLW, 2002)

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Nursing and Patient Safety

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Nursing in Healthcare Institutions
and Medical Accidents
Nursing Accidents• Accidents while providing nursing care (medical
interventions are not involved)• Accidents while assisting medical treatment (medical
interventions are involved)

The Act on Public Health Nurses, Midwives, and Nurses stipulates thescope of practice for nurses in Japan are “to provide nursing care” and“to assist medical treatment.”
Thus, a medical accident involving a nurse may be an accident whileproviding nursing care, or an accident while assisting medical
treatment which involves medical interventions. Due to the nature of
the nursing practice, some accidents may include elements of bothcategories, and it may not be possible to classify it into either one
accident category.
Many more nurses work at healthcare institutions than otherprofessionals. They often are the person who actually perform medical
interventions; therefore, they are more likely to be involved in medical
accidents.

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Medical accidents in healthcare
institutions and nursing(Number reported)

Job title of the person involved in reported medical accidents

2500
2000
1500
1000
500
0

* The “person involved” is the person determined by the healthcare institution to have been involvedin the event; more than 1 person may have been involved in any single event.
Source: The Japan Council for Quality Health Care, “Project to Collect Medical Near-Miss/Adverse Event Information, 2014
Annual Report”: Details of Reports made by Registered Medical Institutions (January–December 2014) http://www.medsafe.jp/pdf/year_report_2014.pdf (in Japanese) (accessed on October 21,2015)

The above graph shows the data from reports of medical accidents
submitted by healthcare institutions for the Project to Collect Medical
Near-Miss/Adverse Event Information. Many medical accidents arereported to involve nurses.
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Medical near-miss events at
healthcare institutions and nursing
Job title of the person involved in reported medical near-miss events(Number reported)

30000
25000
20000
15000
10000
5000
0

* The “person involved” is the person determined by the medical institution to have been
involved in the event; more than 1 person may have been involved in any single event.

Source: The Japan Council for Quality Health Care, “Project to Collect Medical Near-Miss/Adverse Event Information, 2014
Annual Report”: Details of Case Information Reports made by Registered Medical Institutions (January–December 2014)
http://www.med-safe.jp/pdf/year_report_2014.pdf (in Japanese) (accessed on October 21,2015)

An overwhelming number of medical near-miss events reported byhealthcare institutions for the Project to Collect Medical Near-Miss/Adverse
Event Information involve nurses.
* Medical near-miss events include the events that had little impact on the concerned patient, orthe events that were prevented from becoming medical accidents.
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Nurses and medical accidents
Nurses and medical accidents: experience(2013)

A year or
longer

64.5

Less than
year

7.7

58.7

14.6

8.5

1.3

0.3

4.62.410.8

11.0

4.42.9 7.5
0.5

0%

20%
40%
Nursing care
Drainage tube or other tube
Medical device, etc.
Blood transfusion

60%
80%
Drug
Treatment
Examination
Others0.3

100%

Source: The Japan Council for Quality Health Care, “Project to Collect Medical Near-Miss/Adverse Event
Information 2014 Annual Report”: http://www.med-safe.jp/pdf/year_report_2014.pdf (in Japanese)(accessed on October 21, 2015)

According to the data from reports of medical accidents submitted byhealthcare institutions for the Project to Collect Medical Near-Miss/Adverse
Event Information, many medical accidents that involved nursing staff are
related to nursing care, drugs, and/or drainage tubing. The ratios of drug- or
drain-related accidents are higher for nurses with less than a year
experience.

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Newly graduate nursing staff(2013)
0.5
Medical accidents

58.7

Near-miss events

8.4

14.6

56.4

8.1

11.0

0.3

4.42.9 7.5

5.6 2.3 11.5

6.3
1.3

0%

20%

40%

60%

80%

100%

Nursing care

Drug

Drainage tube or other tube

Treatment/procedure

Medical device, etc.

Examination

Blood transfusion

Others

Source: The Japan Council for Quality Health Care, “Project to Collect Medical Near-Miss/Adverse Event
Information 2014 Annual Report”: http://www.med-safe.jp/pdf/year_report_2014.pdf (in Japanese)(accessed on October 21, 2015)

The Japan Council for Quality Health Care, which handles the Project toCollect Medical Near-Miss/Adverse Event Information, analyzed the medical
accidents and near-miss events involving nurses with less than one year
experience. The results of their analyses indicated that the factors associatedwith the events involving nurses with less than one year experience were
either a individual factor or an environmental factor.
Factors concerning individual include: lack of knowledge (experience), wrong
assumptions, lack of risk awareness, etc. Factors concerning the environment
include: insufficient mechanism of appraising knowledge and skills,
insufficient training, obscure or irrelevant rules, etc.
Source: The Japan Council for Quality Health Care, “Project to Collect Medical Near-Miss/Adverse Event Information 2014
Annual Report”: http://www.med-safe.jp/pdf/year_report_2014.pdf (in Japanese) (accessed on October 21, 2015)
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Efforts by Departments of Nursing
Healthcare institutions continue to improve their policies andframework to secure organization-wide safety (see Part 1).
The Departments of Nursing also set specific targets, provide
their guidelines and establish the training framework, etc.
In addition, nursing practice is reviewed and standardized bycommittees appointed by the Department of Nursing and therespective nursing units, as well as through routine nursing
practice to assure patient safety.

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Patient safety in nursing practice
Examples of efforts to assure patient safety in nursing
practice• Prevention of patient misidentification
Have the patient say his/her own name in fullUse of a wristband• Fall prevention
Standardization of the fall risk assessment form
Explanation to the patient and his/her family members
Safe nursing environment (environment with the least possible risk
factors for falls; and the least impact in case of an actual fall)• Prevention of wrong drug administration
Unified writing among professions
Double-checking
Confirm the 6Rs (Right Patient, Right Drug, Right Purpose, Right
Dose, Right Route, and Right Time)

Nurses are required to ensure safety and improve the quality of nursing
through evidence-based practice. Various efforts are made in thenursing practice based on the evidence and outcomes of case analyses.

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Collaboration with other professions
Examples of team-based safety efforts:• The 5S actions: Sort, Set, Shine, Standardize and Sustain
The 5S actions originated in the manufacturing sector. The
work environment and medical safety are improved byputting Sort, Set, Shine, Standardize and Sustain into
action.
• Kiken Yochi Training (KYT; Risk-Anticipation Training)
Small-group based approach to identify, discuss and sharehidden risk factors in the workplace and the phenomenon
triggered by them. The group actually point and call out
risks and the priority action in unison while performing
tasks to solve any risks before acting.
Source: Japan Industrial Safety & Association: http://www.jisha.or.jp/zerosai/kyt/index.html (In Japanese) (accessed on
October 22, 2015)

Nurses’ efforts alone cannot protect patient safety in team-based
healthcare delivery. The healthcare team as a whole has to act.
In any team consisting of a range of professionals with differing
backgrounds, the focus is on the prevention of miscommunication. To
reduce instances of miscommunication in a multi-disciplinary team,some healthcare institutions have introduced Team STEPPS® training,which is aimed to improve teamwork. Some healthcare institutions
also engage in Kiken Yochi Training (KYT: Risk-Anticipation Training), tofacilitate team-based prevention of risks and to nurture a safe
environment.
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Education

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Basic Nursing Education
Content
Foundation
studiesSpecialized
Basic studies
Specializations I

Specializations II

Integration

Credits
Basics of scientific thinking
Understanding of humans, living and society
Human body structure and functions
Diseases mechanism and recovery promotion
Health support and social security system
Basic nursing
Clinical training
Basic nursing
Adult health nursing
Gerontological nursingChild health nursing
Maternal nursing
Mental health and psychiatric nursing
Clinical training
Adult health nursing
Gerontological nursingChild health nursing
Maternal nursing
Mental health and psychiatric nursing
Home care nursing
Nursing integration and practiceClinical training
Home care nursing theory
Nursing integration and practice

Total

13
15
6
10
3
3
6
4
4
4
4
16
6
4
2
2
2
4
4
4
2
2
97

(Appendix 3 of Designated rule for Public Health Nursing, Midwifery and Nursing School and Training school)

Safety-related education was introduced in 2009, when a new
curriculum course in Basic Nursing Education started. “Acquisition ofbasic knowledge about medical safety” is presented in the “Nursing
integration and practice” module; the objective is to assure that newly
graduated nurses will be able to apply the content of their respective
nursing studies into clinical practice and to make a smooth transition to
the clinical frontline.
Reference: MHLW 2007 “Report by the Review Committee on Enhancing Basic Nursing Education”
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Basic Nursing Education
Attainment targets for graduation on patient safety in the Bachelor’s Program
Nursing practice competency: Skills to provide a safe care environment
Attainment targets for graduation

Content of teaching

The student nurse
 Will be able to explain the purpose ofteam-based delivery of safe care in an
organized way.
 Will understand infection control
measures and be able to take thenecessary actions.
 Will understand measures to prevent
medical accidents and be able to takethe necessary actions.

Risk management
Forming a safety cultureStandards of safety
Current state of medical accidents andchallenges
Measures for medical safety
Measures for safety in management of
medical equipment and drugs
Infection control measures
Standard precautions
Prevention of adverse events (e.g.
accidents such as falls, bedsores, etc.)
Iatrogenic health injuries (including druginduced injuries)
Incident reporting

Source: MHLW 2011 “The Final Report by the Review Committee on Nursing Human Resource Development atUniversities”, excerpts

The “Report by the Review Committee on Content and Methods of Nursing
Education” was published in 2011, and the required nursing practice competency
and attainment targets for graduation (draft) were presented. The attainment targets
for graduation concerning patient safety were: “understanding the approach to
medical safety and the role of the nurse;” “understanding risk management;”“understanding safe management of prescription drugs;” “adherence to infection
control protocols;” and “behavior following the guidelines.”“The Final Report by the Review Committee on Nursing Human Resource
Development at Universities,” also published in 2011, presented the core nursing
practice competency for the Bachelor’s Program alongside the attainment targets forgraduation, and also presented such teaching content as “risk management,”“forming a safety culture,” “current state of medical accidents and challenges,”“infection control measures,” “prevention of adverse events,” “incident reporting,”
etc.
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Student nurses’ practical training
and safety
In a report published in 2003, MHLW indicated that it isdesirable for an educational institution and a practicalplacement facility to sign a “Practical Placement Contract
Agreement,” clarifying the responsibilities in case of a medical
accident.

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Continuing education: Medical Care
Act and Medical Treatment Fee
Provision of training to ensure a medical safety
management framework• 2006 Amendment of the Medical Care Act• 2006 Revision of the Medical Treatment Fee

The 2006 Amendment of the Medical Care Act mandated theadministrator of a hospital, etc., to take measures to ensure the safetyof medical care, including the implementation of training of employees.
(Article 6-12. Medical Care Act)
Since 2006, “Establishment of a medical safety management
framework” has become a requirement for healthcare institutions toclaim the basic hospital admission charge as part of medical treatment
fees: to provide the patient with basic medical management andnursing care services and an environment for recuperation while
admitted. “Establishment of a medical safety management framework”
includes implementation of staff training twice a year or so to ensurethat the safety management framework is secure.

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Continuing education opportunity
for nurses• Clinical training for newly graduated nursing
personnel• In-house training by the respective healthcare
institutions• Training by the Nursing Association, etc.

The number of nurses at healthcare institutions is overwhelmingly
larger than any other professionals. They also often become the final
person to perform medical interventions, which is the reason why it
is important to improve nurses’ knowledge about and skills
concerning medical safety to ensure patient safety.
Patient safety-related nursing staff training may involve clinicaltraining for newly graduated nursing personnel; in-house training by
the respective healthcare institutions, as discussed above; andtraining by the Nursing Association, etc. as part of the continuing
education it offers.

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Clinical training for newly graduate
nursing personnel
Clinical Practice Competency

III. Management
aspects

I. Basic stance andattitude required ofnursing staff

II. Technicalaspects

Source: MHLW 2014 “Clinical training for newly graduated nursing personnel guideline (Revised version)”
http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000049466_1.pdf (in Japanese) (accessed on October 21,
2015)

A clinical training for newly graduate nursing personnel has become mandatory
for the establisher of healthcare institutions to make an effort to implement since2010. This training program is expected to improve the quality of nursing andtherefore to ensure medical safety, as well as to prevent newly graduated nursing
personnel from prematurely leaving the profession.
In the “Clinical training for newly graduated nursing personnel guideline (Revised
version; hereinafter referred to as `The Guideline`)”, the government indicatedthe targets to be attained within one year and the criteria for attainment. The
respective institutes implement the program tailored to their unique characters.
As shown above, The Guideline presents the attainment targets in three areas ofclinical practice competency. Regarding patient safety, it is clearly stated, notmerely to follow nursing skill protocols in terms of the technical aspect, but toconfirm all “elements that support nursing skills,” including ensuring medical
safety, before carrying out. In terms of the management aspect, understanding
the medical safety management framework at the concerned institute, andreporting of incidents, accidents and other events are presented as the targets to
be attained within a year.
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Continuing education
Examples of continuing education for nurses• Fall prevention• Prevention of wrong drug administration• Incidents, accidents and other event analyses• Team STEPPS ®
• Kiken Yochi Training (KYT; Risk-Anticipation Training)• Medical Safety Manager training• Medical safety training for new graduates• Medical safety training for nursing managers

A wide range of programs is offered as part of continuing education run
by the Nursing Association, etc. Those training programs also target
nurses who work in the area of long-term care and home visit nursing.
Patient safety training is offered in various forms: theme specific, scope
specific, career ladder specific, etc. There are many opportunities onoffer for nurses to gain knowledge to ensure patient safety andimprove skills.

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