Nursing and patient safety
in Japan
3. Japanese Nursing Association in Action

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
http://www.nurse.or.jp/jna/english/pdf/safety-02.pdf

3. Japanese Nursing Associationin action

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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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History of Japanese Nursing
Association’s Actions forPatient Safety

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History of JNA’s Main Actions
1951

JNA issued a statement concerning the verdict of medication error related to IV injection.
It was JNA’s first action to support a nurse prosecuted for her role in an accident.

1971

Establishment of the “Committee on Legal Protection of Occupational Practice”
The Committee conducted the first national accident survey in 1973.

1998

Revision of “Guideline on Socio-Economic Welfare of Nurses (Medical Accident Edition)”

1999“Urgent Meeting on Medical Accidents” held
Urgent proposals made on risk management and accident prevention on the healthcare
settings: i. Adequate nurse staffing; ii. Post-graduate training system to be established;iii. Establishment of a healthcare team system to provide round-the-clock seamlesshealthcare; and iv. Clarification of the scope of practice and responsibilities of healthcare
workers within a healthcare institution.

1999

Establishment of the “Risk Management Review Committee”
Survey on the medication error incidents; development of “Risk Management Guideline for
Nurse Administrators – Prevention of Medical Accidents through Efforts of Organizations”;
proposal on medical device/equipment activities; and so forth

2000

The first Risk Manager Training Program

2001

Establishment of the Healthcare and Nursing Safety Office
To be the hub of JNA’s actions for patient safety

2001

Launch of Japanese Nursing Association Nursing Professional Liability Insurance Program

2002“Risk Management Guideline for Nurse Administrators – Responses at the time of Medical
Accidents” published

2003

First meeting of “Patient Safety Liaison Meeting” (now “Patient Safety Promotion Meeting”)
held

2013

“Guidelines on Night Shifts and Shift Work for Nurses” published2013“Standard Text for Promoting Medical Safety” published2015

Three-year Plan for Patient Safety Promotion Project

2015“Actions to Take When Unexpected Death or Fetal Death Occurs as a Result of Healthcare”
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Japanese Nursing
Association’s Actions forPatient Safety

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Japanese Nursing Association’s
Actions for Patient Safety
For many years, JNA has provided direct support to its
members by giving advice on such matters as how to prevent
medical accidents and what actions to take when such an
accident occurs.
However, such individual actions at the time of accidents
alone are never adequate to advance our efforts for patient
safety. That has been the reason why JNA has worked inpartnership with the respective ministries, agencies and otherorganizations to endeavor to ensure patient safety actions
such as activities to develop human resources and to enhance
the respective institutions’ preparedness, as well as activities
to promote and to raise awareness for accident prevention.
Currently Japan’s healthcare and long-term care services areundergoing some major changes, and reforms in healthcare
and long-term care delivery frameworks are ongoing.
Against the backdrop of such social changes, JNA has
identified five priority activities for patient safety. Since 2015,
JNA has performed actions under the renewed framework.

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Japanese Nursing Association’s
Actions for Patient Safety
Five Priority Activities• Firmly establishing a patient safety management
framework at healthcare institutions• Strengthening actions to prevent recurrence of medical
accidents involving nurses• Training of medical safety managers based on the realityof healthcare service delivery• Promoting patient safety education for nurses• Securing the safety of medical and long-term care at
long-term care facilities, etc.

Those five priority activities established by JNA in 2015 set
the direction of JNA’s actions to advance patient safety andenhance JNA’s previous activities through strategic actions.
Following are the specific activities JNA carries out
concerning each of those matters.

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Firmly establishing a patient safety
management framework at
healthcare institutions
Two aspects of activities for “Firmly establishing apatient safety management framework at healthcare
institutions”• Improvement and streamlining of laws and regulations
to facilitate establishment of such a framework• Support for respective institutions so that the laws andregulations will actually be established and function

Concerning “Firmly establishing a patient safety management frameworkat healthcare institutions,” JNA has identified two aspects on which to act.
Concerning improvement and streamlining of laws and regulations, JNA,
as a nursing professional organization, has made proposals at various
settings of policy formulation in the interest of nurses whose job is toprovide care, and of our patients. Those occasions included theformulation and revision of national systems such as formulation of theMedical Accident Investigation System, which came into effective in 2015,
as well as other occasions of reviews with the national government andrelated parties such as requirements for accreditation of hospitals andcriteria to evaluate hospital’s medical care functions.
Concerning support for the respective institutions in improvement andstreamlining of such systems, JNA has worked in partnership withprefectural nursing associations and other related parties in such areas asproviding information and collecting useful case studies and sharing thosewith nurse administrators.
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Strengthening actions to prevent recurrenceof medical accidents involving nurses:
Promoting utilization of Medical Accident
Investigation System for the prevention ofrecurrence of medical accidents

Pamphlet “Actions to Take When Unexpected Death or Fetal
Death Occurs as a Result of healthcare”

The Medical Accident Investigation System came into effective on October 1, 2015.
This system has been established with the aim of securing patient safety by
elucidating causes of medical accidents and preventing recurrence of the same
accidents. (Please refer to “1. Patient safety in Japan” of this series among JNA
publications available at http://www.nurse.or.jp/jna/english/pdf/safety-01.pdf )At the launch of this system, JNA prepared a pamphlet titled, “Actions to Take When
Unexpected Death or Fetal Death Occurs as a Result of Healthcare,” to help
understanding and raising awareness of the system so that nurses across the country
can take appropriate actions without confusion if need arises and that the said
system can be utilized in prevention of recurrence of the same medical accidents.
Apart from distributing the pamphlet to nurses across the country, JNA is also
engaged in awareness raising activities through Association’s training workshops,etc.
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Training of medical safety
managers based on the reality ofhealthcare service delivery
Training of medical safety managers
Altogether 5,115 were trained during the FY2000–2014 period(Number trained in the most recent years: 88 in 2013 and 84 in
2014)

JNA started a medical safety manager training program in 2000.
A 2006 amendment to the Medical Care Act mandated therespective healthcare institutions to establish a medical safety
manager position. JNA had recognized the importance of
medical safety managers and started a training program before
the amendment.
In the first stage of our medical safety manager training, aroundthe years 2002–2007, JNA organized events to support medical
safety managers to create a network so that they can facilitate
their actual actions. These days, each region has an establishednetwork and is engaged in its own activities.

Concerning medical safety managers, please refer to “1. Patient safety in Japan” of this series
among JNA publications available at: http://www.nurse.or.jp/jna/english/pdf/safety-01.pdf
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Training of medical safety
managers based on the reality ofhealthcare service delivery
Activities concerning revision of training programs
Making policy proposals
Review of training of those who currently act asmedical safety managers

The Ministry of Health, Labour and Welfare presented work
guidelines for medical safety managers and a guideline forformulating training programs in 2007.
As the healthcare service delivery framework, etc. undergoeschanges in Japan, JNA lobbies the national government toreview the work guideline and the guideline for formulating
training programs, so that those changes are incorporated into
the training programs.
JNA is also reviewing how such training programs are
implemented to improve the skills of those who currently holdthe position, so that the medical safety managers can become
better at fulfilling their roles.

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Promoting patient safety
education for nurses
Providing nurses with information
Purpose• Targeting all nurses, motivate individual frontline
nurses to take responsibility in actively creating asafe environment• Targeting nurse administrators and medical safety
managers, support their management work

JNA provides nurses with information so that they can
improve their skills to provide safe healthcare.

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Promoting patient safety
education for nurses
How medical safety information is provided
JNA website and magazines
Pamphlets
Dedicated consulting service

JNA provides medical safety information through the JNA website,magazines, various pamphlets and the dedicated consulting services.
If the timely availability of patient safety information becomes necessary,such information are published on the JNA website, magazines, etc.
If the information should be widely disseminated to raise nurses’
awareness of it, such information are compiled into a pamphlet for
distribution and awareness improvement. Those prepared pamphlets are
distributed to nurse administrators at healthcare institutions nationwide,
and are also used at training workshops, etc. Such pamphlets preparedso far include “Guideline for checking safe use of EKG monitors in generalwards” (2010) and “Standard Text for Promoting Medical Safety” (2013).
JNA also provides dedicated consulting services concerning patient safety,
which can respond to individual inquiries from our members and others.
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Promoting patient safety
education for nurses“Standard Text for Promoting Medical Safety”

JNA published a “Standard Text for Promoting Medical Safety” in 2013.
JNA had previously published two guidelines on patient safety: “RiskManagement Guideline for Nurse Administrators – Prevention of Medical
Accidents through Efforts of Organizations:,” (1999) on accident prevention,and “Risk Management Guideline for Nurse Administrators – Responses at
the time of Medical Accidents: ” (2002) on post-accident response. Althoughnumerous healthcare institutions utilize those guidelines, there has been agrowing need to review them due to the revision of the Medical Care Act andthe development of a medical safety management framework including
education. Upon reviewing the content and developing this document, JNA
focused on the roles and behavior of nurses at many healthcare intuitions
where standard medical safety measures and a standard medical safety
management framework have been established during the 14-year period
since publication of the 1999 guideline.
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Promoting patient safety
education for nurses“Standard Text for Promoting Medical Safety”
Table of contents
Chapter 1
Basic approach and how to utilize thisdocument
Chapter 2
Basic approach to promote medical
safetyChapter 3
Actions to promote medical safety
Chapter 4
Responses at the time of medical
accidents
Chapter 5
Education“Standard Text for Promoting Medical Safety” is a document thatsystematically presents the course of the medical safety
management process from accident prevention to post-accident
responses. The document provides commentaries on the basic
approach to promote medical safety, specific actions to promote
medical safety and to prevent medical accidents, specific actions
to take at the time of medical accidents, a summary of liabilities,
and medical safety education in basic and continuing nursing
education.
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Nursing professional liability
insurance program
Summary of the scheme
Scheme that covers statutory liability of compensation
for damage or injury if a nurse who works in Japan has
caused a physical injury to another person, damaged aproperty, or violated another person’s personality
rightsScheme that also covers such cases as fortuitous
accidents while working that result in death or
disability, and needle-stick injuries leading to infection
with HBV, HCV or HIV.
• Eligibility: Available to JNA members (for voluntaryenrolment, except midwives in private practice)• Insured period: to be renewed annually
JNA established the Japanese Nursing Association Nursing Professional
Liability Insurance Program in November 2001.
Healthcare services are becoming more advanced and complex,
creating a higher risk for medical accidents while practicing nursing.
There are more cases where a nurse is liable as a person involved in a
medical accident. As nurses are now recognized as more autonomous
profession, they are increasingly required to take responsibility for thedecisions they make, the actions they take and their outcomes. Our
members expressed concern that there might be more cases of
medical accidents ending up in a court of law, where a nurse wasprosecuted. This insurance scheme was established because the
Association considered their voices.
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Nursing professional liability
insurance program
There are several liability insurance schemes for nurses besides
the JNA scheme. However, JNA’s scheme is characterized by its
support system. The scheme is not only cover liability for
accidents but also provide consultation service to members by
establishing “Service Promotion Office”. Even if medical
accidents do not actually occur, it also provides consultation
service on patient safety in routine nursing practice.

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Nurses’ Work and Patient
SafetyJapanese Nursing Association

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Improving work environments
and work conditions for nurses
Patient safety is closely linked to nurses’ work environments.
To protect the lives and health of our patients while providing
safe healthcare, the nurses themselves must be able to worksafely and in good health.
Recent studies of the science of labor found that night shift,rotating shift work and long work hours cause a decline inattention, judgment ability and work performance, whichmight increase the risk of medical accidents. JNA is taking
actions to improve work environments and conditions fornurses based on those findings in the labor science.

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“Guidelines on Night Shift andShift Work for Nurses”
JNA’s “Guidelines on Night Shift and Shift Work for Nurses”
1.
2.

Item
Interval of time
between shifts
Total hours spent at
work

3.

Number of night shifts

4.

Number of consecutive
night shifts
Number of consecutive
working days

5.
6.

Time allocated forbreaks7.

Naps during night shifts

8.

Rest following a night
shift (including days off)

9.

Consecutive days off on
weekends

10. Direction of rotation
11. Start of the morning
shiftStandard
Provide 11 hours or longer time between shifts.
Total hours spent at work are 13 hours or less.
Night shifts should basically be within 8 times a month in asystem of 3 shifts per day. If using another shift system, thenumber should adjust to work hours.
Up to 2 consecutive night shifts.
5 days or less.
Provide 1 hour or more in the middle of a night shift, and a
period according to the length and load of the shift during a
day shift.
Provide an uninterrupted nap time in the middle of the night
shift.
Provide a rest period of 48 hours or more after 2 consecutive
night shifts. A rest period of 24 hours or more is desirable
after 1 night shift.
Consecutive days off over Saturday and Sunday without night
shift before or after should be ensured at least once amonth.
The roster to be forward rotating.
Avoid starting the morning shift before 7 AM.

Based on the basic understanding that “the safety and health of thenurses protect the safety and health of the patients,” this guideline wascreated as a tool to “reduce the burden of the night shift and shift workand manage the risks,” reflecting the actual situation of clinical settingsand knowledge based on labor science. We hope the standards in thisguideline are utilized as reference points to refer to, as well as anindicator or a target for improvement, depending on the situation ateach institution. We work to promote this guidelines.
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