Abstract
Reports of the Cause Analysis Committee of the Japan Obstetric Compensation System for Cerebral Palsy were reviewed to determine whether due consideration was given to “non-punitiveness” and “confidentiality” as required by the World Health Organization (WHO) Draft Guidelines for Adverse Event Reporting System, and also whether consistent criteria were used in medical assessments of different cases. The review results indicated inadequate consideration of confidentiality, as the medical institutions could be identified from the summary versions of cause analysis reports available on the website of the Japan Council for Quality Health Care, coupled with the court's decision letters.
In addition, text indicating “low standard of medical care” was used in 330 of 442 reports (75%). Among them, regarding Caesarean decision, 53 reports (12%) contained wording indicating a possibility of avoiding predisclosure of possible negative outcome to the patient, which could be used in liability pursuit. Regarding the act of replacing a prolapsed umbilical cord, assessment of this same medical procedure varied across cases, indicating a possibility of impaired reliability. Since summary versions of cause analysis reports are open to the public, these issues of report descriptions will require discussion.
