Use of ionic contrast medium in myelography is known to cause a serious state, sometimes leading to death. This type of accident has been repeatedly occurring in Japan and overseas even in the 2010s. Incidental intrathecal injection of contrast medium in epidurography also causes similar adverse events. These cases with the pathology called ascending tonic-clonic seizure syndrome (ATCS syndrome) have been summarized in foreign countries but not in Japan. We therefore collected Japanese cases for review and identified 21 cases, of which 18 (86%) were ATCS syndrome. The outcome was death in 5 cases and recovery in 16 cases, resulting in a recovery rate of 76%. Of these cases, 5 cases were contrast medium selection error, 2 of which were fatal. System factors underlie these cases in that conventional measures such as warning label were insufficient to prevent them. As countermeasures against these catastrophic adverse events, which involve human errors, it is considered necessary for each medical institution to take new expanding prevention and recurrence prevention measures, including review of contrast medium control, education of medical staff involved in testing, and total switch to nonionic contrast medium. Further verification in the academic societies concerned and discussion on recurrence prevention with manufacturers will make these measures more effective.

In this study, we estimated the monetary value of family's burden (unpaid care on everyday life done in-home and in-community by the family, etc.) and nursing care service for dementia covered by the long-term care insurance (LTC) in Japan based on Japanese governmental statistics. From 2001 to 2013, the number of persons supported in-home and in-community with certification of needs of LTC mainly due to dementia, increased 3.22 times from 251,000 to 810,000. During the same period, the average score of such certification decreased from 3.0 to 2.3 (scores higher by severity), the average time of nursing care decreased from 7.0 to 5.4 hours a day, and the average care unit price (opportunity cost method) decreased from 1,155 to 1,042 JPY an hour. As a result, although the cost of LTC became 1.88 times from 0.93 to 1.76 trillion JPY, family's burden increased 2.24 times from 0.66 to 1.49 trillion JPY. The proportion of family's burden also rose from 41.6% to 45.8%.“Deinstitutionalization policy” encourages demented people to receive nursing care by their elderly family at lower opportunity cost, and this may contribute to the increase in family's burden. To obtain care for the elderly whose opportunity cost is low is becoming difficult, resulting in the increase of people who are forced to resign from work to provide nursing care for their aging family members. It would be an important political issue how to balance the family's burden and LCT expenditure at a cost tolerable for a family and other unpaid caregivers.

With the goal of reducing the severe hypoglycemia episode in type 2 diabetes patients, we launched a diabetes team of multidisciplinary cooperation for diabetic patients in our community to prevent severe hypoglycemic unconsciousness. The outcome of our study is to investigate whether it is possible to reduce the incidence of severe hypoglycemia, and improve knowledge to counter-act hypoglycemia through multidisciplinary education. We studied 82 patients with type 2 diabetes brought in by ambulance for severe hypoglycemia in our hospital between April, 2010 to March, 2013. Age, HbA1c, e-GFR, treatment regimen and the relations with the season at the time of the onset was investigated. We found that elderly diabetic patients over 70 years of age on sulfonilurea drugs to maintain HbA1c at 7.0% or less showed higher risk of severe hypoglycemia. We then conducted an investigation regarding their knowledge against hypoglycemia on doctors, nurses and diabetic patients. The results showed a lack of nocturnal hypoglycemia in all three groups. To mitigate this, we distributed coping manuals and brochures compiled by physicians, nurses, pharmacists, administrative dietitian and physical therapists to all related persons. We were able to reduce the occurrence of severe hypoglycemia. Diabetes team approach was effective in decreasing the number of patients with serious hypoglycemic unconsciousness by improving knowledge against the nocturnal hypoglycemia using a brochure. The team medical care, working together and complementing each other, is believed to benefit type 2 diabetic patients.

Polypharmacy is the use of multiple potentially unnecessary medications mainly by elderly patients. It can be associated with an increased risk of adverse drug events, and may also burden the medical economy. Hospitalization is a good opportunity to review medications of elderly patients. Pharmacists are required to assess the appropriateness of therapy, including the dosage, administration schedule, and ongoing need for therapy of all hospitalized patients' medicines.

To identify the problems related to polypharmacy, we examined “pre-avoid”(adverse effect evasion case reports advocated by the Japanese Society of Hospital Pharmacists) reports related to dose reduction or medication discontinuation that occurred in Kyushu Hospital from June 2010 to October 2015.

We identified 488 reports, of which, 71.9% cases involved medications used by patients who were at least 70 years old. Abnormal laboratory values were observed in 58.6% of these cases and were the main reasons that doses were decreased or drugs discontinued. Duplicate therapy was reported in 20.9% cases. A few of the pharmacist-assessed reports described adverse drug reactions or reductions in unnecessary medications. Therefore, we conclude that pharmaceutical care was reasonable in terms of comprehensive assessment, dose adjustment, and prevention of duplicate therapy. In contrast, there were still problems related to polypharmacy such as assessment of the necessity of medication and reductions in the number of pills taken by an elderly patient.

It is important to identify patients who are using potentially inappropriate medications, and to predict the risk of adverse drug reactions. These efforts will help pharmacists identify adverse drug reactions at an early stage and reduce inappropriate polypharmacy.

Single-dose delivery of the injections is one of the important work that connects pharmacists and nurses before injections are administered to the patient based on instruction of the doctor. As part of preparation for receiving accreditation from Japan Council for Quality Health Care (JQ) that recommends single application delivery of injections, we started single-dose delivery of injections using individual containers that can be prepared at a lower cost compared to automation in Nagano Municipal Hospital.

In this study, a survey was conducted on nurses regarding the usefulness of single-dose delivery of injections. The results demonstrated that 86.1% of the respondents evaluated that “injections were easier to take out”, 86.2% evaluated that “injection prescriptions and injections could be verified smoothly”, 86.1% evaluated that “it was more convenient to use containers”, and 74.2% evaluated that “the incidence of confusing injections with another was decreased”, thereby suggesting its usefulness. These results suggested that single-dose delivery of injections using containers is useful in terms of operation, risk and management.

The NHO Himeji Medical Center clinical laboratory received ISO15189 authorization. Thereafter, we added reports of skill-map achievement, “KAIZEN” proposals, and positive feedback among laboratory staff to essential items of all-staff meetings in which all medical technologists and a laboratory doctor attend. As a result, more staff opinions have been received and more than one case has been reported in each meeting on average. The survey to all medical technologists in our laboratory suggested that the staff can gain self-confidence by reporting skill-map achievements, “KAIZEN” culture may grow depending on how their proposals are carried out, and human relationships may be improved by positive feedback among laboratory staff. All-staff meetings have a whole system approach and are useful for creating an active laboratory department.

A questionnaire administered to doctors who had resigned in 2013 from Iwate prefectural hospitals indicated their desire for a reduction of the burden of working day and night. With a sample of 17 Iwate prefectural hospitals, we investigated the number of ambulance and emergency patients, the ratio of primary to secondary emergency patients in secondary medical areas, the number of ambulance transports from secondary medical out-of-service areas, the number of times a single doctor worked a day or night shift alone for a month, and the numbers of emergency patients and patients provided emergency transport who received medical care from a single doctor during one shift and during 1 month in 2014. Although the total number of beds in Iwate prefectural hospitals was 30% of the total number of beds in Iwate, 70% of all emergency transports were to Iwate prefectural hospitals, and originated from almost every secondary medical areas. In total, 80% of emergency patients were primary emergency patients. Numbers of day or night shifts worked by a single doctor in a month in regional hospitals and numbers of emergency patients in flagship hospitals were more than those of other hospitals. At one hospital to which a few residents were assigned, residents treated a higher number of emergency patients and ambulance patients than was the case in other hospitals. In conclusion, the burden on doctors in Iwate prefectural hospitals is quite severe, and managing the distribution of work between primary and secondary emergency cases is of great importance in all hospitals of Iwate Prefecture.

It has been two and a half years since the enactment of medical accident investigation system, and a year since the enforcement, but the understanding of the system and the response of medical institutions and healthcare workers seems insufficient and only 388 incidents have been reported. Insufficient understanding on this system, avoiding commitment while understanding the purpose and value of this system, and guidelines published by healthcare organizations and research groups whose contents are not accordant to regulations might result in confusion and under-reporting. In either case, however, healthcare organizations are requested to follow the regulations.

In this paper, guidelines published by healthcare organizations and research groups were compared to identify the difference of reporting criteria of medical accidents in this system. Eleven guidelines published by healthcare organizations and research groups after the promulgation were examined as for the reporting criteria；‘patient's death caused by medical service’ and ‘unexpected patient's death. We examined the consistency with laws and regulations to compare the way of thinking or the criteria regarding ‘patient's death caused by medical service’ and ‘unexpected patient's death’. In medical institutions and healthcare workers, a uniform decision making for specifying a case which should be reported might be difficult, and it is often needed to determine case by case. As for the boundary cases, it might be needed to accumulate cases to determine whether a case is to be reported or not. To standardize the reporting criteria among guidelines of healthcare organizations and research groups seems effective in minimizing confusion in clinical practice and strengthen the reliability of this system. Appropriate response to this newly introduced system is essential in promoting reliability, patient safety and quality in healthcare.