Healthcare environments can be intense. A lot happens, sometimes very fast, and the stakes are high. Hospitals use incident reporting systems to identify and track adverse events and high-risk situations. These systems give healthcare facilities critical insights to prevent or reduce risks to patients. But adverse events in healthcare are underreported worldwide. Shin Ushiro tells us about Japan’s journey to building a national medical adverse event reporting and learning system and how to consider cultural, organizational, and political contexts in developing incident reporting systems in healthcare.