Analysis of data captured by barcode medication administration system using a PDA; aiming at reducing medication errors at point of care in Japanese Red Cross Kochi Hospital.

Preventing medication errors by using a barcode administration system has become prevalent in patient safety. Analyses of data captured by bar code systems provide opportunities to understand the actual situation at the point of care. Our study aims at understanding issues of medication safety as well as investigating measures taken to prevent medication accidents, by analyzing data captured by a bar code system and a personal digital assistant (PDA). The barcode administration system named Point-of-Act-System implemented in Japanese Red Cross Kochi Hospital was designed to capture every activity at the bedside. Complete activity data captured by the system, which included injections, treatment and other nursing activity, as well as injection warning data, were used for our analyses. We describe the data and analyze them statistically to find potentially times of risk and to ascertain the relation between busyness and error. The injection warning rate as a whole was 6.1% on average. The results showed there was a negative correlation between the number of injections given and the injection warning rate (-0.48, p<0.05). The warning rate was low during the hours when a large number of injections were administered. The data also showed that a variation in activities being performed has a negative effect on medication safety. A bar code administration system is quite an effective way not only to prevent medication error at point of care, but also to improve patient safety through analyses of data captured by such a system.

Repeat surgery for hemolysis 6 years after replacement of the ascending aorta for acute aortic dissection.

A 71-year-old woman underwent replacement of the ascending aorta for Type A aortic dissection. After 6 years, she suddenly developed severe hemolytic anemia, and a second operation for replacement of the ascending aorta was performed. Her hemolysis was thought to occur as follows: the proximal ascending aorta of the graft might have gradually expanded until it compressed the graft. The severe hemolysis was thought to be attributable to disturbance of blood flow by a jet of blood at the site of constriction or the reversed inner felt. Such a case as this is very unusual in that the second operation for hemolytic anemia occurred 6 years after the first surgery.