Patient safety education, including error prevention strategies and management of adverse events, has become a topic of worldwide concern [1–5], but only a minority of programs have formally incorporated patient safety topics into the medical education curriculum [1, 6]. Advocates of patient safety continue to insist the reform of curriculum, with the Association of American Medical Colleges (AAMC) publishing the Medical Schools Objectives Project report advocating patient safety and the United Kingdom House of Commons Health Committee acknowledging educational deficiencies and recommending inclusion in basic medical curricula [7, 8]. An especially poignant guideline by the World Health Organization (WHO) states, “Building students’ patient safety knowledge needs to occur throughout medical school. Patient safety skills and behaviours should begin as soon as the students enter a hospital, clinic or health service… Medical students, as future clinicians, will need to know how systems impact on the quality and safety of health care, how poor communication can lead to adverse events and much more. Students need to learn how to manage these challenges” [9].
Concern about patient safety in Japan
Turning point
Japan’s public interest in patient safety was sparked by two serious medical accidents in the late ‘90s. In Jan. 1999, at the Yokohama City University Hospital, a patient mix-up resulted in surgeons performing a cardiac surgery on a pulmonary patient and a pulmonary surgery on a cardiac patient. In this case, all medical staff including the surgeons, anesthesiologists, and nurses failed to properly identify the patients. In a separate incident in Feb. 1999 at the Hiroo General Hospital, a nurse mistakenly injected an antiseptic into a patient, who immediately died. The mistake resulted from improper storage and labelling of medications. The nurses and physicians involved in these cases were criminally prosecuted. Soon after, backed by public demand, patient safety began to gain notoriety as an area in need of drastic reform, including error prevention, adverse event management, a model project for error reform, and legal liability for error.
Error prevention
Safety advocates began to emphasize the need of education for physicians on medical error theory, such as human factors contributing to error and theories and models of error. In an effort to quantify error rates and systematically analyze errors for prevention measures, the Japan Council for Quality Health Care (JCQHC), an accreditation agency similar to the Joint Commission in the United States, established the “Project to Collect Medical Near-Miss/Adverse Event Information [10].”
More practical topics related to patient safety also gained attention in Japan. Patient relations became a focus of improvement, specifically soliciting feedback from patients about any safety issues they encountered during their hospitalizations. Practical safety habits, such simple things as reading back and confirming orders, gained popularity, too.
Management of adverse events
In the U.S., the Harvard University affiliated hospitals published a consensus paper, “When Things Go Wrong” and more recently the “Sorry Works Coalition” is gaining interest [11, 12]. In England, the National Health Service initiated the “Being Open Project” in 2006 [13]. The need for hospitals in Japan to become more transparent and share their errors with other institutions for the sake of learning and improvement has also been emphasized. Responding to adverse events when they do occur is now regarded as an important part of patient safety, for example, in patient communication, disclosure, and apology [14].
The model project
The government responded to patient safety by establishing a pilot system for dealing with sentinel events leading to patient death. The Ministry of Health, Labour and Welfare (MHLW) launched a “Model Project” for investigation and analysis of healthcare-associated patient deaths in September 2005 [15]. If the regional office accepts a case, the office assembles a 3-person team including physician in the same subspecialty as that involved in the case, a clinical pathologist, and a forensic pathologist to perform autopsy and determine cause of death. A second team interviews hospital staff, reviews the medical record, and encourages the hospital to conduct an internal investigation. Following investigation, a report is issued detailing the medical course of care and conclusions about how the error could have been prevented [16].
Legal liabilities
The number of civil litigation on medical malpractice steadily increased year by year. Physicians were also held criminally liable for error. The Yokohama City University Hospital case and the Hiroo General Hospital case were sentinel cases handled through the Japanese criminal legal system, and a number of subsequent cases of medical error have been handled likewise, with the number of healthcare provider criminal prosecutions for medical error leading to patient death has been on the rise since [17].
Patient safety education at medical schools in Japan
Curriculum guideline in Japan
With so much new activity related to patient safety, the need to educate future physicians about such topics was acknowledged, and in 2008 the Japanese Ministry of Education, Culture, Sports, Science & Technology (MEXT) revised their official medical school curriculum guideline, called the Model Core Curriculum, to include patient safety as part of the core medical curriculum [18]. New guidelines are typically adopted by public medical schools and then private medical schools in Japan, and the effects of these guidelines have yet to be seen.
Teaching format
When schools do decide to teach patient safety, teaching format becomes a topic of interest. In Japan, lecture based learning is still the norm. Lectures are the most efficient in terms of a single person being able to deliver information to a large group, and alternative teaching methods perhaps require more preparation, teaching staff, and effort. However, physician competency requires both foundational knowledge and the ability to apply problem solving skills to practical situations, and recently in Japan alternative teaching methods such as small group learning, role playing, hospital based practical experiences, and student to student teaching, such as through assigned research topic presentations, are gaining popularity. Teaching format is important to effective learning, and this applies to patient safety education, too.
Current safety education teaching at medical schools in Japan
Every other year, the Association of Japanese Medical Colleges (AJMC) publishes a report related to medical education curricula that provides some information about medical safety education [19]. From the report, that lists the title of various courses, and in some cases, the number of hours devoted to each course, based on the title of the course we have positive proof that many schools in Japan have specific courses devoted to patient safety education. Approximately 55% of medical schools list a course that is obviously or conceivably related to patient safety, and where indicated, the range of hours devoted was 6 to over 50 h (from 2005–2009). The school reporting the most curricular hours is Yokohama City University, where the heart-lung accident happened in 1999, indicating it devoted 33, 45, and 52.5 curricular hours to medical safety education in 2005, 2007, and 2009, respectively (over the total 6 year curriculum). However, the informal reports lack detail. Most schools do not list the number of curricular hours; for example, in 2009, only 16/80 schools list hours, producing a median of 16.7 h. In some cases it is unclear how relevant a particular course is to patient safety education (e.g. “Legal Medicine”), and the particulars of courses (content, topics, teaching methods, etc.) are not specified.
The aim of this research
We previously conducted a study to characterize the state of patient safety within the nursing field [20]. However, the current state of patient safety education at medical schools in Japan is not well characterized. We hypothesize that, as thought leaders and early adopters of governmental guidelines, public schools will likely lead private schools in terms of incorporation into the curriculum, and the hours devoted will be greater at public than private institutions. We therefore aim to describe how many hours, what instructional methods, and what specific topics medical schools employ to teach patient safety and if public and private institutions differ in these regards. This information may aid in the decisions of resource allocation and strategy for improving patient safety education in Japan, providing information to the international community about what is achievable in terms of adopting safety education in medical curricula.