Hospitals are too reluctant to investigate causes of fatal cases on their own

To prevent the recurrence of accidents in the medical field, it is essential to investigate their causes. For the sake of progress in medicine, there is a need to create an environment to fully verify why accidents have occurred.

Regarding medical accidents, a system to prevent similar incidents from happening again was established in 2015. Under the system, medical institutions are required to report accidents that result in the unexpected death of a patient to the Medical Accident Investigation and Support Center, a third party under the jurisdiction of the Health, Labor and Welfare Ministry, and conduct an investigation on their own.

The number of accidents reported under the system in the past year was only 277 cases, the lowest number on record. Even with people refraining from visiting medical institutions due to the novel coronavirus pandemic, the number fell by more than 100 cases compared to when the system began. Some medical professionals have also said that the number of reports does not reflect the actual situation.

However, partly due to the medical community protesting such investigations, claiming that such inquiries could lead to imposing blame on doctors and nurses, it is left to the discretion of each medical institution whether to report medical accidents to the center.

It is not uncommon for the bereaved families of patients to criticize medical institutions for not conducting investigations. The reluctance by medical institutions to investigate cases can be a factor that shakes the relationship of mutual trust on the patients’ side.

The family of a man who died of brain damage after hitting his head while hospitalized in Osaka Prefecture in 2019 asked the hospital to investigate the cause, but no such investigation was conducted.

After learning that other hospitals had investigated similar cases, the bereaved family became distrustful and filed a lawsuit. If the hospital had dealt with the matter sincerely, the situation might have turned out differently.

Recently, the family of a man who died after heart surgery at the National Center for Global Health and Medicine Hospital was dissatisfied that an investigation based on the system would not be carried out, so they asked an expert to analyze the case and a paper was released stating that there was a problem with the operation.

The hospital later reported the case to the Medical Accident Investigation and Support Center as a medical accident. One year and eight months had passed since the patient’s death. An in-house investigation will now begin, but it is important to ensure that there is no doubt about the fairness of the investigation by, for example, appointing disinterested third parties as the members in charge of the investigation.

The medical accident investigation system must be reformed so that both reports and investigations are properly conducted. Instead of the medical institutions concerned deciding alone whether to report, it is advisable that measures be considered such as having a third party or an academic society participate in the decision, or establishing reporting standards.

It is also said that medical institutions tend to be reluctant to report medical accidents out of fear that their reputation will be damaged. However, unless investigations are conducted, problems could arise again without the causes being clarified. It is also vital to listen to the families of those who have died.

(From The Yomiuri Shimbun, Oct. 19, 2022)