Committee for Medical Safety Report : Example of Minor Incidents in the Preparation of Kampo Products in Pharmacy

Toshiaki Makino; Mariko Sekine; Koichiro Tanaka; Saori Shimada; Atsushi Chino; Eiichi Tahara

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Committee for Medical Safety Report : Example of Minor Incidents in the Preparation of Kampo Products in Pharmacy

VernacularTitle:医療安全委員会報告～漢方製剤に関する薬局ヒヤリ・ハット事例
Author: Toshiaki MAKINO ¹ ; Mariko SEKINE ² ; Koichiro TANAKA ³ ; Saori SHIMADA ⁴ ; Atsushi CHINO ⁵ ; Eiichi TAHARA ⁶
Author Information

1. Department of Pharmacognosy, Graduate School of Pharmaceutical Sciences, Nagoya City University
2. Center for Evidence-Based-Medicine, Oriental Medicine Research Center, Kitasato University
3. Department of Traditional Medicine, Faculty of Medicine, Toho University
4. Department of Pharmacy, University of Tsukuba Hospital
5. Department of Japanese Oriental (Kampo) Medicine, Chiba Central Medical Center
6. Department of Japanese Oriental (Kampo) Medicine, Oriental Medical Center, Iizuka Hospital
Keywords: minor incidents; Kampo products; pharmacists; separation of medical and dispensary practice; medical safety
From:Kampo Medicine 2020;71(4):394-401
CountryJapan
Language:Japanese
Abstract: We collected and analyzed the case reports of minor incidents in the preparation of Kampo products in Japanese pharmacies in order to manage the medical safety control in Japanese traditional Kampo medicine. We extracted 2,166 reports that are related to Kampo products from the database of minor incidents in pharmacies supplied from The Japan Council for Quality Health Care from 2009 to 2019. Among the reports, we found the cases that pharmacists could find the mistakes about the name, dosage and administration of Kampo products or could prevent the appearance of adverse reaction when pharmacists check the prescription and ask prescription question for doctors. It is suggested that the system of separation of dispensing and prescribing functions would be well working in medical safety control. At the same time, we also found many cases that pharmacists have actually made mistakes by confusing the name of Kampo products and dosage. In this report, we summarized the cases of these minor incidents and frequently appearing confusions about the names of Kampo products.