Objective: We report preventive measures of missing drug administration in hospital setting, based on factor analysis. Methods: The double-check system was introduced to prevent from missing drug administration. In order to evaluate the effectiveness of the preventive measures, the type of errors was classified into seven patterns as follows; 1: Instructions and/or prescriptions were forgotten/ inappropriate instruction were given, 2: Lack of recognition of instructions, 3：Misunderstanding of instructions, 4: Forgot to prepare medications , 5: Forgot to hand medicine to patients , 6: Forgot to confirm drug administration, 7: Others . The number of cases for each pattern was analyzed calculated, and the effects of preventive measures were compared before and after implementation of preventive measures. We extracted the factors behind each factor that led to missing drug administration even after the measures were taken, and examined the preventive measures. Results: The number of cases of missing administration of medication was 193 in 2014 (before the implementation of preventive measures,) and 83 in 2018 ( after the implementation of preventive measures) with decrement by 57%. Factor 1 remained unchanged, Factors 2, 3, 4, and 5 were decreased by 74%, 75%, 46%, and 48%, respectively, while Factor 6 was increased. Factor 2 was most seemed to reflect in the effect effectiveness of the measures, and with decrement from 92 cases to 24 cases, and the ratio to the total non-medication decreased from 48% to 29%, showing a significant difference (P ‹0.01). Factor 6 was increased even after the measures were taken, which might be related to mixture of patient and medical staff factors. Conclusions: Analysis of missing drug administration has clarified both effectiveness and problems of preventive measures by double-check function.

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Purpose: A pharmaceutical package insert is an only drug information based on the Japanese law. By revised rule of pharmaceutical package inserts and paperless movement, the digitization has been considered. However, it is unclear how doctors are checking pharmaceutical package inserts. Methods: In January 2020, a questionnaire was provided to participants in the General Medicine In-Training Examination (GM-ITE). Results: A total of 6,869 residents (539 hospitals) participated in the GM-ITE. Of these, we analyzed the responses of 5,468 residents who fully responded to the survey. 537 residents (9.8%) belonged to Special Functioning Hospitals, and 4,931 residents (90.2%) belonged to other hospitals. 1,749 (32.0%) residents responded that they checked all pharmaceutical package inserts they ordered, 3,497 (64.0%) checked them among high-risk drugs only, and 222 (4.1%) never checked. There was no significant difference between the status of checking pharmaceutical package inserts and the affiliation (p=0.20). Discussion: This is the first nation-wide survey to investigate the status of checking pharmaceutical package inserts. Since some serious drug errors have occurred due to inadequate confirmation of the package insert, it is desirable to consider how to provide a practical package insert and to develop a method to disseminate and educate the public about the revised content.

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Objective: The objective of this research was to review the changes over four years in the complaints from patients and/or their families after educational fall prevention measures were taken. Methods: Educational information on the prevention of falls through things such as brochures, was provided in February 2010 to patients without cognitive dysfunction who needed assistance with ambulation. This intervention was evaluated by physicians, nurses, and other healthcare workers at a University hospital A through an anonymous self-administered questionnaire survey conducted from 2010 to 2013. The questionnaire included questions about complaints from the patients themselves or their families during their falls or near-falls. The responses were analyzed by the Kruskal-Wallis test, followed by multiple comparisons and calculation of the effect sizes. Results: This research showed that there was a significant decrease in the number of complaints that physicians perceived they received from the patients and/or families, and physicians and nurses did other health care providers received from them. Conclusion: The results suggested that provision of educational information on the prevention of falls to patients may have reduced complaints from the patients and them families.

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Objective: Due to countermeasures against the new COVID-19 infection, conventional face-to-face and group classes are no longer available. The Education Committee of the Council for Medical Safety Management of National University Hospitals conducted a questionnaire survey on the transformation of undergraduate medical safety education, including the implementation of online classes, under the COVID-19 disaster, and issues for the future. Methods: The Education Committee prepared survey items and conducted a questionnaire survey using Google Form to member and observer schools of the Council. Results and discussion: We received responses from 42 of the 46 university hospitals (response rate: 91%). The most common types of classes that were difficult to implement due to the COVID-19 disaster were group lectures and practical training. In online classes, 30% to 50% of the universities did not offer question-and-answer sessions with students, evaluation of teaching effectiveness, or hands-on training. Conclusion: Online classes are still in their infancy and have many challenges. Information on advanced approaches needs to be shared among universities.

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Background: Many open-ended documents in incident reports (IRs) lack sufficient information regarding the facts. Consequently, it difficult to effectively prevent future incidents. In this study, we examined the descriptive method to improve readability and designed and implemented a training. We evaluated the usefulness of the training and the descriptive method. Methods: Twelve IRs were analyzed, organized for missing information and obfuscations, and summarized in a descriptive method. Next, the training to simulate the description of IR using our method was designed and conducted with 57 residents and 97 new nurses. To evaluate the usefulness of this study, we conducted a questionnaire and calculated the number of words and frequent words in the IR. Results/Discussion: The descriptive method included 5W1H as follows: sentences were itemized based on time of events, each sentence was kept short, and a subject was included in each sentence. As a result of the training, the number of words increased, and the frequency of the subjects representing the people involved in the incident increased. The relationship between the parties involved and the event became clearer. Additionally, short, chronological bullet points were found to improve the readability of the IR. Opinions regarding the training were generally positive.

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Vietnamese hospitals, in the first stage of quality and safety in healthcare, required innovators to introduce new ideas to improve healthcare quality and safety. From 2017 to 2019 as an international cooperation with Vietnam, the National Center for Global Health and Medicine (NCGM) produced 29 Vietnamese graduates from four rounds of training in Japan on quality and safety in healthcare. NCGM supported the graduates to hold three on-site forums called “Vietnam forum on hospital quality management and patient safety”. Every forum had an increase in the number of participants from 58 participants from 28 organizations in the first forum to 223 participants from 53 organizations in the third forum. In the graduates’ affiliations, the proportion of participants from the graduates decreased from 24% to 10% while the proportion of the other participants increased from 29% to 43%. The number of organizations other than the graduates’ affiliations increased by 38 in the second forum, and by 30 in the third forum compared to 17 in the first forum. In addition, the third forum accepted visitors from the neighboring country of Laos (19 participants from 6 organizations). This suggested that the graduates influenced both their affiliations and other hospitals in and outside of Vietnam. This project demonstrated that international cooperation was able to accelerate the adaptation of new concepts like quality and safety in healthcare, and actual practices that fit the local context.

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[in Japanese]

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[in Japanese]

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