2021_Book_TextbookOfPatientSafetyAndClin

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33 Lessons Learned from the Japan Obstetric Compensation System for Cerebral Palsy: A Novel System… 467 not attributed to a medical procedure conducted by a physician, that is, cases that were inevitable during clinical care. 3. A unique national system should be established for settling disputes, functioning independently of the judicial court system. Regarding the first point, the JMA Physician’s Liability Compensation System was launched in 1973 in line with the indemnity insurance system. However, neither the second nor the third point were realized in the following decades. In the early 2000s, concerns about patient safety, the shortage of obstetricians and pediatricians, and low national birth rates rapidly emerged in Japan. This eventually prompted the JMA to publish a report entitled “Toward Compensation in Cases Related to Medical Management and Procedures” in January of 2006. It states that “although it is ideal to launch a compensation system to cover entire medical specialties, a compensation system with a narrower scope for cases with neurological sequela, i.e., cerebral palsy, should be given the highest priority for institutionalization.” The JMA board member who supervised the compilation of the report was an obstetrician and vice president who, years later, became the president of the Japan Association of Obstetricians and Gynaecologists (JAOG). In August of 2006, the JMA published another report compiled by a project committee on the progress of the implementation of a compensation system for disabilities caused by cerebral palsy. It set forth concrete and detailed reasons to launch a no-fault compensation system specific to cerebral palsy. The project was further promoted by a report from the Policy Research Committee of the Liberal Democratic Party (LDP) which was at the time and still is a member of a leading political alliance. The report was titled “The Framework of No-fault Compensation System for Obstetric Care,” commonly referred to as the “LDP Framework.” The report described the perceived significance of launching no-fault compensation system for cerebral palsy by declaring, “It usually is difficult to identify malpractice regarding an adverse event during delivery, and those cases are apt to be contested in court. The frequency of disputes is one reason for the shortage of obstetricians.” The LDP Framework proposes that, to secure safe and trustworthy perinatal care that benefits obstetricians, patients, and families, a new system should: (1) compensate patients who develop impairments possibly caused by adverse obstetric events, (2) swiftly resolve and settle all disputes, and (3) improve the quality of obstetrical care by investigating cerebral palsy cases. Immediately upon the release of the LDP Framework, significant official and unofficial attention focused on JQ, proposing that it should be an operating organization for the novel system. JQ was the natural choice because it had previously conducted projects on quality and safety improvement, such as hospital accreditation and Adverse Event Reporting and Learning Systems. In response to high expectations, JQ established in 2007 the Division of Introductory Work on the Japan Obstetric Compensation System for Cerebral Palsy (JOCS-CP) as a temporary agent to introduce the JOCS-CP in Japanese healthcare system. At this point, it should be noted that political decision added momentum to the growing demand by academic society to launch the JOCS-CP; JQ was considered to be the right choice to operate the JOCS-CP because it was a neutral body related to quality and safety improvement in healthcare. The secretary installed in JQ for working on the JOCS-CP during preparatory period intensively studied potential obstacles for the launch of a system and, in January of 2008, finally issued a report which described the detailed design of the system. After careful review of the report, the JQ board accepted the role of managing organization of the system in March of 2008. Subsequently, the JOCS-CP was launched on the 1st of January 2009, and has been in operation since, undergoing a revision in 2015 that saw the expansion of eligibility criteria with the full support of stakeholders.
468 33.2 The Meaning of “No-Fault Compensation” in the JOCS-CP The term “no-fault compensation” could be defined in multiple ways. Besides the JOCS-CP, another compensation system in Japan—a system regarding medication side effects, managed by the governmental Pharmaceuticals and Medical Devices Agency (PMDA)—has been described as a no-fault compensation system because it compensates individuals who suffer medication side effects provided that the medication was prescribed and administered appropriately and that the medication is the probable cause of the adverse side effects. The system is designed based on the idea that adverse side effects can occur even when appropriate medication is prescribed and administered. On the other hand, no-fault compensation might refer to a system which provides compensation no matter the degree of any suspected negligence. This is an idea of the JOCS-CP which is different from the one adopted by the civil judicial system. Specifically, the LDP Framework states that the JOCS-CP will compensate patients with cerebral palsy that was possibly caused by delivery procedures regardless of the extent of obstetrical negligence. Therefore, cerebral palsy cases obviously caused by congenital defects, such as cerebral anomalies, and thus not related to the obstetrical procedures are not eligible for compensation under the system. 33.3 Compensation Driven by the Indemnity Insurance Mechanism S. Ushiro et al. The two main pillars of the JOCS-CP are compensation and investigation/prevention (Fig. 33.1). Compensation works through a mechanism of indemnity insurance services provided by the alliance of indemnity insurance companies under contract with JQ, as indicated in “The Framework of the No-fault Compensation System in Obstetric Care” (Fig. 33.2). As described within this framework, a childbirth Linkage to public health care insurance Raised lumpsum birth allowance Raised delivery fee Insurance premium Public Insurance Pregnant Woman Childbirth Facility Indemnity Insurance payer / Baby Firm Monetary Compensation (Insurance money) Fig. 33.2 Finance
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Textbook of Patient Safety and Clin
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Liam Donaldson • Walter Ricciardi
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Foreword As a member of the 17th le
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Preface Despite the extensive atten
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Acknowledgements The volume editors
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xii Contents 11 Adverse Event Inves
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Part I Introduction
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4 explain how to prepare and update
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6 considered preventable) [11]. Fur
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8 W. Ricciardi and F. Cascini the l
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10 W. Ricciardi and F. Cascini inte
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12 maximized or perhaps even realiz
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14 steps in obtaining, managing, an
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16 quality improvement methodologie
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18 99. Morciano C, et al. Policies
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20 Reason travelled the world makin
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22 For each hospital unit, other do
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24 As head of clinical risk managem
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26 R. Tartaglia Table 2.1 Differenc
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28 R. Tartaglia Open Access This ch
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30 otherwise efficient brains lead
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32 • A routine violation is basic
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34 Table 3.1 Framework of contribut
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36 H. Higham and C. Vincent The con
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38 H. Higham and C. Vincent recogni
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40 H. Higham and C. Vincent Table 3
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42 assessment and prevention was no
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44 of human error, 2nd: 1983: Bella
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46 ment of theories on how to deliv
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48 all times, not only when there i
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50 healthcare, pursued by enthusias
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52 15. National Academies of Scienc
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54 In this chapter, I will reflect
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56 hospital, there may be 50 indivi
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58 medicals, these are part of the
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60 facility and could therefore bec
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62 health. It is hoped that the Che
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64 Medication Without Harm, invites
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66 21. World Alliance for Patient S
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68 death of my late husband, Pat, f
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70 S. Sheridan et al. test. A separ
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72 enced some kind of harm due to h
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74 S. Sheridan et al. member of The
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76 6.7.1 Example: Canada 6.7.1.1 Wo
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78 All stakeholders must accept, va
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Human Factors and Ergonomics in Hea
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7 Human Factors and Ergonomics in H
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Patient Safety in the World Neelam
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8 Patient Safety in the World 95 8.
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8 Patient Safety in the World adopt
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Infection Prevention and Control An
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9 Infection Prevention and Control
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The Patient Journey Elena Beleffi,
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10 The Patient Journey 119 End of e
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10 The Patient Journey 121 Fig. 10.
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10 The Patient Journey advocates) i
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10 The Patient Journey Table 10.2 T
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10 The Patient Journey 7. Internati
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130 from these interactions that pe
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132 Data integration is certainly t
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134 organizational processes, such
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136 Table 11.3 Scheme of contributo
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138 tocol requires one or more exte
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140 system failure. Quantification
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142 8. Carayon P, editor. Handbook
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144 similar industries, in terms of
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146 (2002) argue is a more effectiv
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148 for research in patient safety
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150 hospital in Kenya with focus on
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152 Haines et al. (2002) proposed a
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154 G. Dagliana et al. Fast Track -
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156 G. Dagliana et al. 11. Jha AK,
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Part III Patient Safety in the Main
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162 development of new receptor ant
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164 Physician burnout and the psych
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166 S. Damiani et al. Fig. 13.1 In
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168 mortality and has rapidly becom
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170 ing to patient safety and share
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172 ability to cope with the workin
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174 2. Vlayen A, Verelst S, Bekkeri
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Safe Surgery Saves Lives Francesco
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14 Safe Surgery Saves Lives manner
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14 Safe Surgery Saves Lives not yet
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14 Safe Surgery Saves Lives In a su
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14 Safe Surgery Saves Lives 14.15.1
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14 Safe Surgery Saves Lives • Tea
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Emergency Department Clinical Risk
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15 Emergency Department Clinical Ri
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206 • Pragmatic: in a healthcare
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208 Risks associated with pregravid
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210 Table 16.1 Common and Recurrent
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212 improved clinical surveillance
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214 (only IM wards or all medical w
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216 M. L. Regina et al. Table 17.1
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218 Table 17.2 Types and preventabi
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220 nicians were certain resulted w
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224 Table 17.6 “Debiasing questio
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226 in care. At a minimum, medicati
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228 cation rates there substantiall
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230 well-structured, concise, focus
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232 M. L. Regina et al. Fig. 17.3 W
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236 Table 17.14 Risk factors for as
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238 Table 17.16 Common risk factors
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240 In patients with kidney disease
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242 Table 17.19 Clinical response t
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244 stones. Giordano’s test posit
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246 in practice. Swiss Med Wkly. 20
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248 procedures done by general inte
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250 tion: a systematic review and m
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252 162. Improvement IfH. What is a
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254 and therapeutic strategies, all
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256 direct effect of radiotherapy o
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258 obtaining treatment consent and
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260 A. Marcolongo et al. Table 18.1
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262 A. Marcolongo et al. Toxicities
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264 nies that are aimed at building
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266 A. Marcolongo et al. tissues. B
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268 and breast cancer) and can be r
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270 happened during the first three
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272 40. World Health Organization (
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Patient Safety in Orthopedics and T
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19 Patient Safety in Orthopedics an
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Patient Safety and Risk Management
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20 Patient Safety and Risk Manageme
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Patient Safety in Pediatrics Sara A
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21 Patient Safety in Pediatrics eve
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21 Patient Safety in Pediatrics of
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21 Patient Safety in Pediatrics Cri
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21 Patient Safety in Pediatrics of
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Patient Safety in Radiology Mahdieh
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22 Patient Safety in Radiology The
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22 Patient Safety in Radiology indu
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22 Patient Safety in Radiology CA a
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22 Patient Safety in Radiology Refe
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Organ Donor Risk Stratification in
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23 Organ Donor Risk Stratification
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23 Organ Donor Risk Stratification
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326 M. Plebani et al. Fig. 24.1 The
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328 ical laboratory and the definit
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330 • Findings of external accred
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332 M. Plebani et al. Fig. 24.2 Mod
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334 laboratory medicine professiona
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336 (WHO) website on the incidence
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338 54. Magnezi R, Hemi A, Hemi R.
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340 In 2010 this condition represen
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342 which should be slightly smalle
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344 needed by the pulse waveform to
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346 washed properly prior to steril
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348 ocular reaction without infecti
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350 large retrospective cohort stud
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352 • Lack of appropriate skills.
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354 scription [126]. Furthermore, a
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356 time and knowledge to young doc
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358 48. Barry P, Gettinby G, Lees F
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360 implant versus intravitreal ant
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Part IV Healthcare Organization
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366 causes of safety incidents and
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368 • Human factors such as teamw
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370 access to the Emergency Room. F
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372 that many doctors simply choose
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374 E. Alti and A. Mereu Open Acces
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376 components (people, technology,
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378 J. Braithwaite et al. Hence, cl
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380 stakeholders to figure out how
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382 J. Braithwaite et al. Clinician
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384 27.5.3 Social Networks in a War
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386 J. Braithwaite et al. Fig. 27.9
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388 representations the essential l
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390 21. Pomare C, Churruca K, Ellis
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Measuring Clinical Workflow to Impr
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28 Measuring Clinical Workflow to I
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Shiftwork Organization Giovanni Cos
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29 Shiftwork Organization influenci
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29 Shiftwork Organization Many epid
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29 Shiftwork Organization quences o
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29 Shiftwork Organization in shift
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Non-technical Skills in Healthcare
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Page 473 and 474: 476 (c) (d) (e) (f) (g) (h) (i) (j)
Page 475 and 476: 478 115 bpm to 80 bpm and complete
Page 477 and 478: 480 • It is desirable that system
Page 479 and 480: 482 cific monitoring procedures (1)
Page 481 and 482: 484 Res. 2019;45(3):493-513. https:
Page 483 and 484: 486 19. In the most severe cases, t
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Page 491 and 492: 494 M. Tanzini et al. the mother, p
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