Hi there!

In this article, I will share a story about Gifu Prefecture where I’ve gone skiing many times.

About 6 months ago The Gifu Municipal Government told a woman who underwent a stomach cancer screening test that no abnormalities had been found, despite her really requiring further detailed testing (July 16, 2019). The woman consequently died of stomach cancer.

This incident turned out to be caused not only by a simple mistake but due to a problem with the way it was processed. I feel bad for the victim, and her bereaved family might feel tremendous regret and sadness. On the other hand, the person who made the mistake and the people who were involved also might have a hard time (though it doesn’t mean I defend the organization or the person who made the mistake).

In this article, I will consider the thorough management of workflows as the precaution against those kinds of mistakes.

Overview of the Cancer Screening Operation and Errors

A woman who had a stomach cancer screening test in January 2019 died on July 16th of that year.

The Gifu Municipal Government sent the notification of no abnormalities to the woman on January 28th. However, lung cancer which was found to have spread from stomach cancer was later found in the woman.

The test result was notified by The Gifu Municipal Government

According to the available information on the website of The Gifu Municipal Government, locals can receive notification of the results of a stomach cancer screening test through the following process:

  • The screening test is held in the medical examination cars parked around the public halls and the community centers.
  • After the screening test, the collected data (X-rays, results of the medical consultation, etc.) is sent to the medical institutions where the judgment of the test is made.
  • The Gifu Municipal Government receives the test results from the medical institutions.
  • The Municipal Government creates a notification of the test result and sends it to the recipients.

The Gifu Municipal Government inputs the screening results into the system. I’m not sure of the details but the system can possibly make a notification with an easy-to-understand description for the patient and send it.

The general flow of the operation of stomach cancer screening tests
The general flow of the operation of stomach cancer screening tests

Reading and verifying not implemented to compensate for input errors

The Gifu Municipal Government checked the result of the screening test, and they found an error in the notification.

“The woman underwent testing at a different medical facility in April, where it was learned that she had lung cancer that had metastasized from her stomach. Her family became suspicious about her previous test result and when they checked with the Central Public Health Center on July 10, the city admitted it had made a mistake. City officials apologized the following day.”

The Mainichi: https://www.asahi.com/articles/ASM7J5HLVM7JOHGB00D.html

The results of the screening tests are sent to The Gifu Municipal Government from the medical institution, but the officials entered the wrong values in the system*.
*The purpose and mechanism of the system are still not clear.

In the operation manual, after the test results received from medical institutions are manually entered into the system, they should have been read and the results checked for any errors. However, that was not done thoroughly.

“Officials said that notifications sent to people following cancer screening tests are based on test results sent from private medical institutions. As a general rule, two workers are supposed to read and verify the results, but only one worker did so this time, and made a mistake.”

The Mainichi: https://mainichi.jp/english/articles/20190717/p2a/00m/0na/011000c
The general flow of notification preparation work
The general flow of notification preparation work

In Gifu city, 3 public health centers and the Health Promotion Division are involved in the operation of the medical tests, and as the article says, this mistake occurred at the Central Public Health Center. On the other hand, at the North Public Health Center, the South Public Health Center, and the Health Promotion Division, there were no false reports because they read and verified the results.

Ignored operation manual

Comparing the procedures with other centers, the mistake the Central Public Health Center made obviously stemmed from the third party’s failure to check the entry of the test results in the system. Why did this happen? Why was the operation manual ignored? Despite the fact that reading and verifying are rules in the manual.

I think there were issues in the following 2 points.

  • Sharing the results
  • Handover

I will explain in more detail below.

Sharing business performance results

Not having read and verified them for many years suggests that the results of business operations were not properly shared. Sharing might seem similar to making a report, but it’s not just about informing your supervisor. Sharing – I will explain here – is intended to convey information widely to interested parties and to record information for future reference.

If “reading” work is recorded and shared with your boss or other stakeholders, you’re more likely to notice if it doesn’t happen.

Handover of operations

Unfortunately, the task of reading and verifying was skipped and handed over from the predecessor.

If the successor already understood the importance of the manual, they would have realized some errors and taken the opportunity to correct them. However, it might have been difficult to do so on the site where the operations were proceeding. Also, it is possible that handing over the operation was too costly because of routine work.

It is necessary to think of ways to ensure that the essence of business succession is conveyed. At the same time, the cost must be kept low.

Summary

The accident in Gifu city described in this article stemmed from the fact that operations did not proceed according to the manual.

In order to improve this, I consider that the following improvement points are necessary

  • Make sure that the results are shared so that interested parties can be aware that work is proceeding according to the manual
  • Ensure that the handover of operations is carried out appropriately and affordably

In the next article, “Workflows of Stomach Cancer Screening Tests“, I’ll describe exactly how to achieve this improvement.


References

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