Investigation of Medical Accidents: Improve The System So That Fairness Is Ensured

Editorial

16:29 JST, July 20, 2025

Even if there is a system to investigate the causes of medical accidents, that system will not prevent recurrence unless it is used effectively. It is urgent to improve the mechanism.

The Health, Labor and Welfare Ministry has begun discussions by a panel of experts on how to improve the safety of medical services. According to the ministry, the panel aims to decide on the course of its discussions by this autumn.

The focus of the talks will be issues related to the medical accident investigation system.

The investigation system was introduced in October 2015, following revisions to the Medical Service Law. It requires medical institutions to conduct internal investigations and report to third-party organizations when a patient dies unexpectedly at a medical institution.

The system is aimed at preventing the recurrence of medical accidents. There is a great significance in using investigations for improving the quality and safety of medical services. They will also help address the concerns of bereaved families, who want to know the truth when a fatal accident occurs.

However, this system has repeatedly been criticized for its problems. Since the decision whether to identify an incident as a medical accident is left to the discretion of the head of the medical institution, many facilities are reluctant to conduct investigations.

At Kobe Tokushukai Hospital in Kobe, a number of patients died following catheter-based therapies for the heart and other organs, but the hospital did not conduct a thorough investigation. After receiving a whistleblower report, the Kobe municipal government conducted an on-site inspection of the hospital two years ago, and an investigation based on the system was finally carried out.

Disputes between medical institutions and bereaved families also persist. It is necessary to establish a mechanism where third-party organizations urge medical institutions to carry out investigations and make reports, rather than leaving the matter solely to the autonomy of medical institutions. It is also important to provide clear criteria for determining which cases are covered under the system.

There is also the challenge of ensuring the quality and fairness of investigations.

In a case involving the sudden death of a patient who underwent an endoscopy at Juntendo University Hospital in Tokyo, the hospital’s internal investigation found no issues. However, a third-party investigation carried out at the request of the bereaved family concluded that the procedure was “difficult to describe as appropriate.”

If medical institutions cannot be trusted regarding the results of their own investigations, the system cannot be said to be functioning properly. It is essential for the government and the medical community to collaborate to establish and promote reliable investigation methods and to make the system more widely used.

Another issue that has been raised is the fact that investigations are not conducted unless a patient dies.

Medical treatments inherently carry risks, and having no accidents is almost impossible. Therefore, it is the responsibility of medical institutions to deal with medical accidents squarely and make every effort to prevent recurrence.

(From The Yomiuri Shimbun, July 20, 2025)