Objectives: The initiation of medicine-related deaths is assumed to be classified as intermediate causes of death representing significant outcomes and comorbidities in the death process. However, as pathological autopsies are drastically decreasing, most medicine-related death investigations are estimated based on clinical information. To share autopsy findings in medical safety activities, we created a database focusing on intermediate causes of death and analyzed the characteristics of medical practices that affected the causes of death.

Subjects and Methods: From January 1991 and December 2020, we extracted the underlying, intermediate, and immediate causes of death in 107 autopsy cases of hepato-biliary-pancreatic diseases, created the database, followed by comparing the characteristics of the intermediate causes of death related to medical safety in three 10-year periods.

Results: Intermediate causes of death in association with medical safety were shown in 2/41 cases in the first period, 1/18 in the second period, and 11/48 in the third period, with a significant increase in the third period compared to the first period (p<0.05). Only two medical accidents regarding a CV catheter and a thoracic drain were recognized through 1st to 2nd periods, while the third period happened many kinds of accidents associating with a CV port, a pleural puncture, a liver biopsy, a nephrostomy, a radiation-associated liver injury, and drug-induced lung injury and immunosuppression. The infectious diseases also revealed significant increase in 3rd decade than those in 2nd period (p<0.01).

Conclusion: These finding suggested that enrichment of the cause-of-death database focused on the intermediate causes of death would be expected to contribute to the search for similar cases and to the sharing and utilization of the knowledge leading to the analysis of medicine-related deaths even cases without performing hospital autopsies.

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Although non-technical skills (NTS) have been introduced in hospitals and other clinical settings as a method to reduce errors caused by human factors, NTS have yet to be introduced in community pharmacies, and there are few studies related to NTS in community pharmacies.

Therefore, this study was conducted to investigate the relationship between incidents and NTS in community pharmacies. In Company K, which operates six community pharmacies, 67 incidents were submitted from pharmacies to the headquarters between October 2019 and September 2020; these incidents were analyzed by two evaluators, and the results indicated that NTS were associated with more than 80% of the incidents. Assessments using the kappa statistic showed a moderate level of inter-evaluator agreement. The NTS-related incidents were classified based on the NTS categories proposed by Flin et al., and the top three categories of “situational awareness”, “decision making”, and “leadership” accounted for more than 70% of the total. These findings suggest that there is a relationship between incidents and NTS in community pharmacies. In the future, it will be necessary to study and develop frameworks and systematic educational programs for NTS tailored to community pharmacies.

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The Department of Pharmacy Services at Ikuwakai Memorial Hospital shares drug and patient information with other medical or nursing facilities using a patient information form. This process is also used for health insurance pharmacies. However, there have been few reports on the content and utility of these forms for interinstitutional information sharing between hospital pharmacies and medical or nursing facilities. Thus, we evaluated the use of these forms for information provision in the period from October 2017 to September 2020. Forms were completed if there was a need to communicate information about a patient, such as a change in prescription during hospitalization. During the study period, 233 forms were delivered to health insurance pharmacies or medical or nursing facilities at the time of discharge. Of these forms, 131 were collected and aggregated in a questionnaire survey of the utility of the forms. Patient information forms were viewed as helpful at more than 80% in other medical or nursing facilities, which confirmed the utility of the forms at these facilities. Our findings emphasize the importance of active provision of information by hospital pharmacists to other medical or nursing facilities to support safe drug therapy.

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[in Japanese]

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Purpose: This article is an organized and expanded version of the panel discussion “Introduction to Psychological Research for Medical Professionals: From Mere Fact-finding Surveys to Journal-ready Questionnaire Studies” at the 17th Annual Meeting of the Japanese Society for Quality and Safety in Healthcare. As an introduction to psychological research methods, the article aimed to explain in an easy-to-understand the knowledge necessary for medical professionals to conduct questionnaire studies.

Structure: Following the introduction (I), an overview of psychological research methods (II) is given. Then, along with the research progression procedure, the points to know and pay attention to are explained regarding how to formulate questions and hypotheses (III), create questionnaires (IV), conduct statistical analysis (V), conduct surveys (VI), and write the manuscript (VII).

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