Medical Safety Committee Report :Medical Accident Information and Minor Incidents from Medical Institutions Related to Kampo Products
- VernacularTitle:医療安全委員会報告（2020）～漢方製剤に関する医療機関からの医療事故情報及びヒヤリ・ハット事例～
- Author:
Mariko SEKINE
1
;
Toshiaki MAKINO
2
;
Koichiro TANAKA
3
;
Saori SHIMADA
4
;
Junko YOKKA
5
;
Eiji FURUYA
6
;
Atsushi CHINO
7
;
Eiichi TAHARA
8
Author Information
- Keywords: patient safety; Kampo medicines; medical accidents; minor incidents
- From:Kampo Medicine 2021;72(2):182-203
- CountryJapan
- Language:Japanese
- Abstract: The Medical Safety Committee analyzed the case reports of minor incidents from the pharmacies last time as part of an activity to promote patient safety in Japanese traditional Kampo medicine. This time, we analyzed the case reports of medical accidents and minor incidents from the medical institutions. We extracted 626 reports related to Kampo products from the public database, which the Japan Council for Quality Health Care has established based on the collected information related to the medical accidents and minor incidents. The medical accident information includes case reports related to drug-induced liver injury. The minor incident reports include prescribing error due to misinterpretation related to the quantity of one sachet of Kampo extract product, dispensing error due to similarity of product appearance, number or name, and administration error due to judging the medicine only by Kanji characters or product company names without checking the Kampo formula name. Additionally, the minor incidents were often discovered by people belonging to different professions or patients themselves. In order to promote patient safety, knowledge about these incidents should be shared among the people involved in the same or different professions.
