ABSTRACT

Patient safety in Japanese health care settings became an issue of public interest in 1999, when the incorrect identification of two patients at a university hospital resulted in each patient receiving the surgery intended for the other. Since then, hospitalwide patient safety programs have been implemented, including system-oriented preventive measures based on incident reports (Nakajima et al., 2005) and a national reporting system for serious adverse events. All efforts have focused on failure from a classical safety perspective (Safety-I), hypothesising that when things go wrong there must exist specific causes to be fixed, such as errors and non-compliance.