Kampo Risk Management Based on a Survey on Incident and Accident Cases at Specialized Kampo Medicine Facilities

Mariko Sekine; Toshiaki Makino; Koichiro Tanaka; Saori Shimada; Junko Yokka; Eiji Furuya; Atsushi Chino; Eiichi Tahara

Return

Kampo Risk Management Based on a Survey on Incident and Accident Cases at Specialized Kampo Medicine Facilities

VernacularTitle:漢方専門施設におけるインシデント・アクシデント事例の実態調査から考える漢方リスクマネージメント～日本東洋医学会医療安全委員会活動報告（2021）～
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

1. Center for Evidence-Based-Medicine, Oriental Medicine Research Center, Kitasato University
2. Department of Pharmacognosy, Graduate School of Pharmaceutical Sciences, Nagoya City University
3. Department of Traditional Medicine, Faculty of Medicine, Toho University
4. Department of Pharmacy, University of Tsukuba Hospital
5. Toyama University Hospital
6. Department of Pharmacology, Showa University School of Medicine
7. Department of Japanese Oriental (Kampo) Medicine, Chiba Central Medical Center
8. Department of Japanese Oriental (Kampo) Medicine, Oriental Medical Center, Iizuka Hospital
Keywords: medical safety; specialized Kampo medicine facilities; incident and accident cases; decoction; risk management
From:Kampo Medicine 2022;73(4):448-462
CountryJapan
Language:Japanese
Abstract: The Medical Safety Committee has conducted various activities for patient safety in Japanese traditional Kampo medicines. In this study, we conducted a questionnaire survey to promote the prevention of medical accidents and their recurrence. We received responses from 15 of 19 facilities specializing in Kampo medicine and collected a total of 247 incident and accident cases in the field of Kampo medicine. Cases of side effects included interstitial pneumonia caused by Kampo prescriptions containing Scutellariae Radix, aconite poisoning, and licorice-induced pseudoaldosteronism. Furthermore, we also collected decoction-specific cases, which are unique to facilities specializing in Kampo medicine, for the first time. From the results, we included the following seven points for risk management in the field of Kampo medicine : 1) insufficient recognition to the side effects of Kampo medicines, 2) misunderstanding of the dosages of Kampo products, 3) errors due to similarities in Kampo formulas and crude drug names, 4) preconception of frequently used Kampo prescriptions, 5) contamination in the decoctions, 6) errors related to crude drug items and their dosages that are frequently added or subtracted, 7) errors in hospital wards.