Logo of qualsafetyQuality and Safety in Health CareCurrent TOCInstructions for authors
Qual Saf Health Care. Apr 2005; 14(2): 123–129.
PMCID: PMC1743978

A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital


Problem: When patient safety programs were mandated for Japanese health care institutions, a safety culture, a tool for collecting incident reports, an organizational arrangement for multidisciplinary collaboration, and interventional methods for improvement had to be established.

Design: Observational study of effects of new patient safety programs.

Setting: Osaka University Hospital, a large government-run teaching hospital.

Strategy for change: A voluntary and anonymous web-based incident reporting system was introduced. For the new organizational structure a clinical risk management committee, a department of clinical quality management, and area clinical risk managers were established with their respective roles clearly defined to advance the plan-do-study-act cycle and to integrate efforts. For preventive action, alert procedures, staff education, ward rounds by peers, a system oriented approach for reducing errors, and various feedback channels were introduced.

Effects of change: Continuous incident reporting by all hospital staff has been observed since the introduction of the new system. Several error inducing situations have been improved: wrong choice of drug in computer prescribing, maladministration of drugs due to a look-alike appearance or confusion about the manipulation of a medical device, and poor after hours service of the blood transfusion unit. Staff participation in educational seminars has been dramatically improved. Ward rounds have detected problematic procedures which needed to be dealt with.

Lessons learnt: Patient safety programs based on a web-based incident reporting system, responsible persons, staff education, and a variety of feedback procedures can help promote a safety culture, multidisciplinary collaboration, and strong managerial leadership resulting in system oriented improvement.

Full Text

The Full Text of this article is available as a PDF (139K).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • O'Neil AC, Petersen LA, Cook EF, Bates DW, Lee TH, Brennan TA. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med. 1993 Sep 1;119(5):370–376. [PubMed]
  • Cohen MR. Why error reporting systems should be voluntary. BMJ. 2000 Mar 18;320(7237):728–729. [PMC free article] [PubMed]
  • Takeda Hiroshi, Matsumura Yasushi, Nakajima Kazue, Kuwata Shigenori, Zhenjun Yang, Shanmai Ji, Qiyan Zhang, Yufen Chen, Kusuoka Hideo, Inoue Michitoshi. Health care quality management by means of an incident report system and an electronic patient record system. Int J Med Inform. 2003 Mar;69(2-3):285–293. [PubMed]
  • Maass G, Cortezzo M. Computerizing incident reporting at a community hospital. Jt Comm J Qual Improv. 2000 Jun;26(6):361–373. [PubMed]
  • Mekhjian Hagop S, Bentley Thomas D, Ahmad Asif, Marsh Gail. Development of a Web-based event reporting system in an academic environment. J Am Med Inform Assoc. 2004 Jan-Feb;11(1):11–18. [PMC free article] [PubMed]
  • Busse DK, Wright DJ. Classification and analysis of incidents in complex medical environments. Top Health Inf Manage. 2000 May;20(4):1–11. [PubMed]
  • Wu Albert W, Pronovost Peter, Morlock Laura. ICU incident reporting systems. J Crit Care. 2002 Jun;17(2):86–94. [PubMed]
  • Wolff AM, Bourke J, Campbell IA, Leembruggen DW. Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program. Med J Aust. 2001 Jun 18;174(12):621–625. [PubMed]
  • Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, Hallisey R, Ives J, Laird N, Laffel G, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995 Jul 5;274(1):35–43. [PubMed]

Articles from Quality & Safety in Health Care are provided here courtesy of BMJ Group


Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...


  • Cited in Books
    Cited in Books
    PubMed Central articles cited in books
  • PubMed
    PubMed citations for these articles

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...