Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly.

BACKGROUND: To analyse a medical accident, much time and experience are needed. However, people without experience in analysis have difficulty understanding its conditions and methods, and as a result it takes longer to establish countermeasures. It must be noted that understanding conditions by simply aligning occurrences in the accident in a chronological order is difficult. PURPOSE: A workflow chart that considers time was proposed so that individuals without adequate experience in analysis could easily carry out root cause analysis. METHODS: In the 'workflow chart (WFC)', the time sequence was described horizontally. On the vertical axis, the business manual, the occurrence of the accident, and the time of the occurrence are displayed. In the bottom column of patient event, information regarding damage to patients was written in accordance with time axis. Regarding the degree of damage, the time of error until the accident was identified was connected using a straight line (when the patient was not affected, a dotted line was used) in order to show the overall picture of the accident. RESULTS: According to the time flow chart, hints to identify potential risks were proposed. Focus was placed not only on the error event, but also on keywords such as manual inadequacy, time gap, degree of error and so on to easily lead to the question 'why?' To visualise this, I proposed an operation flow chart. By using time-WFC, even beginners can easily develop accident countermeasure strategies. CONCLUSION: Using a WFC that considers time, time of error and the occurrence of accident could be visualised. As a result, even individuals without experience in analysis could easily perform an analysis.

[Inter-laboratory Study of an HPLC-UV Method for Free Asparagine in Grains].

In order to validate an HPLC-UV method for the determination of free asparagine, which is a precursor of acrylamide, in grains using dansyl derivatization, an inter-laboratory study was performed in 9 laboratories using 5 kinds of grains (non-glutinous brown rice flour, corn flour, strong flour, whole wheat flour, and whole rye flour), which naturally contain free asparagine. The relative standard deviations for repeatability (RSDr) and reproducibility (RSDr) were in the ranges of 0.5-2.2 and 2.3-5.9%, respectively. The HorRat values ranged from 0.4 to 0.6. These results were within the range of the procedural manual of the Codex Alimentarius Commission, and therefore the method is effective.

Highly stereoselective synthesis of C-vinyl furanosides through acid-catalyzed S(N)2 inversion at the C-3 position of 1,2-dideoxy-hept-1-enitols.

A highly stereoselective synthesis of C-vinyl furanosides through the S(N)2 inversion at the C-3 position of the 1,2-dideoxy-hept-1-enitols is disclosed. Treatment of the 1,2-dideoxy-hept-1-enitols with diphenylammonium trifluoromethanesulfonate as the acid catalyst produced the C-vinyl furanosides (3,6-anhydro-1,2-dideoxy-hept-1-enitol derivatives) via a subsequent S(N)2 intramolecular debenzyloxyation-cycloetherification reaction at the C-3 position.

Analysis of medical accidents using the "Why Why Why Analysis" (questions): comparison with conventional analytical techniques.

Techniques such as 4M-4E matrices and the SHEL model have been proposed in recent years as tools for analyzing medical accidents and developing countermeasures. There have been hardly any reports, however, describing their use for the development of risk strategies in the medical setting. After using the SHEL model, Toranomon Hospital is currently using "Why Why Why Analysis" and has had several successes as a result of its use. With this in mind, a comparative study was conducted between "Why Why Why Analysis" and several previously reported accident countermeasure tools, root cause analysis (RCA), used at Veterans Hospitals in the US, and quality control (QC), used in the industrial sector. As a result, "Why Why Why Analysis" as applied in radiology work was determined to be easy to deploy even for beginners as compared with the other tools, able to accommodate complaints as well as accidents, and useful on the basis of having both practical and expandable functions for improving radiology work.