Medical Safety Committee Report :Medical Accident Information and Minor Incidents from Medical Institutions Related to Kampo Products / 日本東洋医学雑誌

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.

Forensic Review of the Medical Accidents Related to the Iatrogenic Injury of Neck Vessels: The report of four autopsy cases / 대한법의학회지

Four cases medical accidents related to the iatrogenic injury of neck vessels are reported. The first case was a 54-year-old woman. Under the diagnosis of the herniated cervical disc, the operation was performed. After five hours from starting the operation, respiratory difficulty, facial cyanosis and syncope were found, suddenly. The autopsy finding were large hematoma at the posterior portion of neck organ and perforation of right carotid artery. The second case was a 61-year-old woman. Under the diagnosis of the aneurysm of the anterior communicating artery, the coiling and embolization were performed. After one hour from removal of catheter of right carotid artery, respiratory difficulty, facial cyanosis and syncope associated with right neck hematoma were found, suddenly. Eventually, she died after 41 days due to hypoxic brain injury. The third case was a 55-year-old woman. Under the diagnosis of the thyroid cancer, total thyroidectomy was performed. After three hours from operation, respiratory difficulty, facial cyanosis and syncope associated with severe neck hematoma were found, suddenly. Eventually, she died after 25 days due to hypoxic brain injury. The last case was a 34-year-old man. He visited the hospital due to stab wound of left neck. The irrigation and simple suture were performed at the first visit. After he went home, respiratory difficulty and syncope were found, suddenly. He returned the hospital and cardiopulmonary resuscitation was performed. However, he died. The autopsy finding were large hematoma around the neck organ and stab wound of left carotid artery.

Discussion about judicial discretion in medical malpractice arbitration / 中华医院管理杂志

Results of medical malpractice arbitration are important evidence and proofs for public health departments and judicial institutions to handle properly disputes over medical accidents. Owing to the flaws that exist in the structure of medical malpractice arbitration, arbitration specialists sometimes find it difficult to accept the evidence and proofs. The author of the present paper suggests that judicial discretion be introduced in medical malpractice arbitration. When exercising judicial discretion, the specialists should comply with the following principles: (1)Review objectively the evidence and proofs provided by both the physicians and patients according to law. (2)Ensure neutral arbitration according to the ethics of arbitration. (3)Apply specialized knowledge, clinical experience and logical inference. (4)Make independent and lawful judgments and draw definite conclusions. Anyone who exercises judicial discretion should do so in the light of laws and regulations and bear corresponding legal responsibilities.