Understanding institutional conversion: the case of the National Reporting and Learning System

4 July 2012

Geary Researcher Nao Kodate (newly appointed lecturer at the UCD School of Applied Social Science) organised and participated in the secondAnglo-Japanese collaboration for Improving Patient Safety (AnJIPS) event, which was held between 4th and 7th June in Tokyo. Dr Kodate, former Research Associate at the NIHR King’s Patient Safety and Service Quality Research Centre (King’s College London, KCL) has been leading the AnJIPS project. It is a one-year project funded by the Daiwa Anglo-Japanese Foundation, and its first event took place in October 2011 in London.

The four-day event in Tokyo was hosted by Dr Kenji Harada (Assistant Professor, Department of Health Care Safety Management, The University of Tokyo (UT)), along with his team. Together with three delegates from KCL, Nao took part in a one-day research seminar, a meeting with the risk manager at the UT Hospital, a discussion with a group of relatives of harmed patients (who recently launched a non-profit organisation with the aim of building partnerships between patients and medical professionals in the event of adverse medical events), and observations of simulation training sessions (a classroom-based ER training session using mannequin at UT, and a high-fidelity ward-based training module for newly qualified nursing staff at the Terumo Medical Pranex.

During the seminar, Dr Kodate and the delegation presented findings from various research projects including risk management and incident reporting systems in acute care and mental health settings, evidence of increasing use of simulation training in anaesthesia (just published in British Journal of Anaesthesia, 109, 1, 99-109. doi:10.1093/bja/aes184) and public and patient involvement in the management of English hospitals. Common challenges facing both countries in the realm of patient safety and quality improvement were repeatedly highlighted. They included learning from incident data, shortage of well-trained staff in risk management techniques, empowerment of patients and certain medical professionals, search for an effective modality of medical education and regulation in order to ensure high standards of care in hospitals. Differences between the two countries in the legal system and the processes of policy developments were also identified.

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