[What we must learn from recent medical accidents--experiences at the investigation committee]

The current publicity of medical accidents in Japan started with two well-known accidents. On January 11, 1999, a cardiac patient underwent a pulmonary operation, while a pulmonary patient received cardiac surgery at Yokohama City University Hospital. On February 11, 1999, detergent was inadvertently injected into a venous line at Hiroo Hospital in Tokyo. The author was invited as an indifferent specialist to serve on the Investigation Committee for these two accidents. This article describes the lessons to be learned from these two accidents.