Patient SafetyMedicine and Medical Science

M.D., Ph.D. Professor Yumi Matsumura

Patient safety is the basis and core principle of all medical services. The World Health Organization has estimated that 1 in 10 inpatients suffer some type of medical injury. The goal of patient safety is to minimize preventable medical harm to patients. Our Department of Patient Safety was established in June 2017 and conducts the following research:
1.Measures against human errors that result in serious accidents
2.Issues in the complex and advanced medical care delivery system
3.Differences in the perception of risk between patients and healthcare providers

Lab Website

Research and Education

  1. Identifying logical and effective methods of checking
    • Comparing the effectiveness of single- and double-checking for the safety of drug administration We replaced our double-check strategy with a single-check strategy for the preparation of medications, excluding specified high-risk medications, in two of the wards in our hospital to examine its effect on the safety of drug administration.
      Our results showed that the number of reported incidents and their level of severity did not change after transitioning from the double-check strategy to the single-check strategy.
  2. Identifying an effective management system to reduce adverse events associated with high-risk medications and medical devices
    • Incidents of life-threatening adverse events associated with symptoms specific to molecular-targeted drugs and effectiveness of strategies to mitigate such events
  3. Medical accident investigation system
    • Values in implementing an open disclosure system as part of the medical accident investigation system

Figure:
The number and level of reported incidents did not change between the double-check period (8 months prior to the implementation; 94,828 medications) and the single-check period (8 months after the implementation; 85,790 medications).
Level 0: near miss, Level 1: no harm incident, Level 2: mild adverse event not requiring any treatment

Table: Time spent on cross-referencing for injectable medications, per 100 medications Note: Ward A manages a mean of 210 medications/day, and ward B manages a mean of 120 medications/day

Recent Publications

  1. Matsumura Y. Risk Analysis of Eculizumab-Related Meningococcal Disease in Japan Using the Japanese Adverse Drug Event Report Database. Drug Healthc Patient Saf. 2020 Nov 10;12:207-215. doi: 10.2147/DHPS.S257009. eCollection 2020
  2. Kodama S, Matsumura Y, Hattori T, Sato K: Clinical perspectives from Japan. Asian Bioethics Review 7: 410-412, 2015
  3. Matsumura Y, Fujimoto Y, Uemoto S, Ichiyama S: A Strategy for Building Expert Team to Resume Liver Transplantation after Experiencing its Temporal Discontinuation. Healthcare and safety 4: 9-22, 2015

Laboratory

Professor:Yumi Matsumura
Assistant Professor : Takashi Yamamoto, Tatsuto Nishigori, Karin Kato

TEL:+81-75-751-4694
FAX:+81-75-751-4563
e-mail:patientsafety@kuhp.kyoto-u.ac.jp
URL: https://safety.kuhp.kyoto-u.ac.jp/

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