Family escalation in Japan:
Challenges and ongoing initiatives
In Japan, Rapid Response Systems (RRS) have been gradually implemented; however, activation remains almost entirely dependent on healthcare professionals. The concept of patient- and family-initiated escalation has not yet been widely adopted.
Key challenges
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Limited visibility of preventable adverse events
At a national level, the epidemiology of in-hospital cardiac arrest (IHCA) and serious adverse events is not fully established. As a result, the extent of potentially preventable deterioration remains unclear, making it difficult to build public awareness and a sense of urgency around the need for family escalation.
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Cultural barriers to speaking up
In Japanese healthcare settings, patients and families may hesitate to express concerns or question clinical decisions. Respect for medical authority and fear of being perceived
as disruptive can prevent timely escalation — even when deterioration is clearly recognized by family members.
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Hierarchical clinical structure
Escalation pathways are often strongly hierarchical, and bedside concerns may not always be promptly transmitted across clinical teams. Introducing family activation may be perceived as bypassing established processes, raising concerns about workflow disruption among healthcare professionals.
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Lack of public awareness of RRS
RRS itself is not widely recognized among the public in Japan. Without a foundational understanding of the purpose and function of escalation systems, meaningful family participation cannot be effectively implemented.
Ongoing initiatives
Recognizing these challenges, we initiated a national effort in 2025 to explore the feasibility and acceptability of family involvement in RRS. This initiative focuses on listening to patient and family voices as a starting point, rather than imposing a system from the medical side. In collaboration with “Japan National Patient Safety Collaborative”, a dedicated web-based platform has been developed to collect perspectives from the public.
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Educational outreach
A short video has been developed to illustrate real-world scenarios in which families recognize patient deterioration but face difficulty in communicating their concerns to the clinical team.
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Experience and opinion collection
Members of the public are invited to share their experiences related to in-hospital emergencies, near-miss events, or situations where their concerns were not adequately addressed.
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Qualitative data generation
These narratives are being collected to better understand barriers to escalation and to inform the design of a culturally appropriate system for Japan.
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Public engagement and community outreach
We are planning a series of public symposia and community lectures to broaden
awareness among the public. These events aim to reach patients, families, and community members across Japan, fostering a wider national conversation about the role of families in patient safety.
Current barriers
Through early engagement with patients and families, several important issues have emerged:
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Difficulty in discussing experiences related to preventable harm or unexpected death
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Emotional burden associated with recalling adverse events
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Limited opportunities for patients and families to safely express dissatisfaction or concern
These findings suggest that, in Japan, building a culture that genuinely supports speaking up is a prerequisite for implementing family escalation systems.
Future directions
Our approach is to gradually develop a Japan-adapted model of family escalation through the following steps:
Raising awareness
· Enhancing public awareness of patient safety and RRS
Psychological safety
· Creating psychologically safe channels for patients and families to express concerns
Engagement
Engaging healthcare professionals to build consensus and reduce resistance
Evidence
· Generating evidence based on real-world experiences in Japan
Rather than directly adopting international models, our goal is to co-develop a system with patients, families, and healthcare providers — one that reflects the cultural and structural context of Japanese healthcare.
Call for experiences
Have you ever felt that something was wrong during a hospital stay?
We are collecting experiences from patients and families across Japan. If you or a loved one noticed a change in condition during hospitalization — and felt unheard, uncertain, or unsure how to speak up — we would like to hear from you. Your voice can help shape a safer system for everyone.
All experiences are welcomed: near-miss situations, unexpected deterioration, moments when concerns were not adequately addressed, or simply times when you wished there had been a clearer way to raise an alarm.
