Recently, the medical incident reporting system has been used in many hospitals andstrategies for prevent accidents from occurring are being put in place. During the period of three months from April through June 2008, a total of 36 incidents were reported in our hospital. Of the total, 15 incidents (41.6%) took place owing to personnel's inattention. Our way of taking preventive measures was reactive, and we tended to become oblivious of the latest accident over time and repeated the same mistake. In order to maintain our consciousness on accident prevention, we have recently started using 10 minutes during the morning assembly to remind ourselves of what we should do -- such as identifyingpatients, confirming injections and medications, and exchanging needles -- through role-play and questions and answers. Three months after this practice got started, the number of the accidents due to inattention reduced to seven cases. In response to a questionnaire survey, almost all the nurses said that the repeated practice helped raise their awareness of accident prevention. The use of 10 minutes in the morning for accident prevention enabled them to start their work with their seat belt fastened. We thought this also contributed to accident reduction.

The following report illustrates a rare case of dysphagia caused by secondary adrenal insufficiency in a patient with isolated ACTH deficiency. A 76-year-old man with progressive appetite loss, weight loss and general fatigue was hospitalized due to dehydration, aspiration pneumonia and hypoglycemia. He was unable to stand and walk by himself. His serum cortisol and ACTH levels were both low. An endocrinological examination resulted in a diagnosis of isolated ACTH deficiency. Following the administration of 15mg of glucocorticoids daily, his symptoms diminished without dysphagia. Furthermore, we investigated his swallowing function using a videofluoroscopic examination of swallowing (VF). The VF showed an impaired laryngeal movement as well as an upper esophageal opening and severe aspiration without a delay in his swallowing reflex. Oral intake was judged to be impossible, but his swallowing function gradually improved and he was able to resume eating all of his meals 2 months after treatment. Dysphagia is not a common symptom in ACTH deficient patients but a few similar cases have been reported. The swallowing function of the patients in these cases was not evaluated in detail, so we evaluated this case according to the results of the VF and the patient's process of recovery. Careful monitoring of swallowing function and appropriate treatment for both dysphagia and adrenocortical failure are required for the recovery of such patients. In conclusion, practitioners should be wary of isolated ACTH deficiency in elderly patients with progressive weight loss and dysphagia.

To clarify characteristics of home care in rural areas in Japan, we investigated the actual status of home care in a rural area (Asuke town, Asahi town, Inabu town, northern part of Toyota city and Shimoyama village) in Aichi prefecture. The subjects were 149 patients who were under medical care and nursing supervision at home for the last 2 years and a half. Age, sex, ADL, prognosis, principal care-givers of the patients and distance from patients' houses to our hospital were compared with the average data of all the nurse stations in Japan (1996). The percentage of patients over 90 years old was 23.4% in this area as against 13.5% of the national average. Sex and ADL levels were similar to the average. The proportion of females as principal care-givers of patients was 80%, which is about average. However, the proportion ofdaughters-in-law was 51.7%, double of the national average. In 48 cases (32%), the time required to get to the hospital by car was over 31 min. This ratio was 3 times higher than that of the average data, and it took 50 min from farthest patient's house (35km). In prognosis, 66 patients died-44 cases (67%) in hospital and 22 cases (23%) at home.
Our questionnaire survey regarding patients' and care-givers' wishes was responded to by 38 of 47 principal care-givers who utilized our home care and nursing survice program. One half of care-givers were over 60 yearsold and had taken care of a patient for over 5 years. Mental stress, feeding and toileting were major problems most principal care-givers cited. However, they required services at a day-care institution for elderly patients and recovery of used paper diapers. Death at home was wished by 23 (61%) patients and care-givers, if they received enough medial care and welfare services.
These findings revealed that elderly people take care of elderly patients, their houses are far from the hospital and they wish to die at home. More collaboration among all providers of medical care and health and welfare services, and the establishment of an information network are necessary to improve these problems, resulting in safe, acceptable and satisfied home care for patients and care-givers.