Search

BACKGROUND: The past half century has seen the near eradication of transfusion-associated hazards. Intraoperative cell salvage while widely used still poses significant risks and hazards due to human error. We report on a case in which blood collected from a patient with lung cancer was mistakenly administered to a patient undergoing cardiac surgery who should have received his own collected blood. The initial investigation found that the cause of the patient harm was violations of procedures by hospital personnel. A detailed investigation revealed that not only violations were the cause, but also that the underlying causes included haphazard organizational policies, poor communication, workload and staffing deficiencies, human factors and cultural challenges. CASE PRESENTATION: On August 14, 2019, a 72-year-old male was admitted to our hospital for angina pectoris and multivessel coronary artery disease. Cardiac surgery was performed using an autologous salvage blood collection system, and there were no major problems other than the prolonged operation time. During the night after the surgery, when the patient's blood pressure dropped, a nurse retrieved a blood bag from the ICU refrigerator that had been collected during the surgery and administered it at the physician's direction, but at this time neither the physician nor the nurse performed the required checking procedures. The blood administered was another patient's blood taken from another surgery the day before; an ABO mismatch transfusion occurred and the patient was diagnosed with DIC. The patient was discharged 65 days later after numerous interventions to support the patient. An accident investigation committee was convened to analyze the root causes and develop countermeasures to prevent a recurrence. CONCLUSION: This adverse event occurred because the protocol for intraoperative blood salvage management was not clearly defined, and the procedure was different from the standard transfusion practices. We

Megumi Takahashi,1 Hiroshi Okudera,2 Masahiro Wakasugi,2 Mie Sakamoto,2 Hiromi Shimizu,3 Tokie Wakabayashi,3 Tsuneaki Yamanouchi,3 Hisashi Nagashima2 1Department of Quality and Patient Safety, Tokyo Medical University, Tokyo, Japan; 2Department of Crisis Medicine and Clinical Safety, University of Toyama, Toyama, Japan; 3Department of Medical Management Office, Toyama University Hospital, Toyama, JapanCorrespondence: Megumi Takahashi, Department of Quality and Patient Safety, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku, Tokyo, Japan, Tel +81 3 3342 6111 Ext 3939, Fax +81 3 5339 3791, Email megu3@tokyo-med.ac.jpPurpose: Our aim was to inform a new definition of wrong-patient errors, obtained through an analysis of incident reports related to medication errors.Methods: We investigated wrong-patient medication errors in incident reports voluntarily reported by medical staff using a web-based incident reporting system from 2015 to 2016 at a university hospital in Japan. Incident report content was separately evaluated by four evaluators using investigational methods for clinical incidents from the Clinical Risk Unit and the Association of Litigation and Risk Management. They investigated whether it was the patient or drug that was incorrectly chosen during wrong-patient errors in drug administration in incident reports and assessed contributory factors which affected the error occurrence. The evaluators integrated the results and interpreted them together.Results: Out of a total 4337 IRs, only 30 cases (2%) contained wrong-patient errors in medication administration. The cases where the intended drugs were administered to incorrect patients occurred less frequently than cases where the wrong drugs were administered to the intended patients through the investigation of wrong targets. After a discussion, the evaluators concluded that the patient - drug/CPOE screen mismatch, caused by choosing the wrong patient, drug, or CPOE screen (mix-ups), occurred in the

In this study, we identified a previously uncharacterized skeletal satellite cell-secreted protein, R3h domain containing-like (R3hdml). Expression of R3hdml increases during skeletal muscle development and differentiation in mice. Body weight and skeletal muscle mass of R3hdml knockout (KO) mice are lower compared to control mice. Expression levels of cell cycle-related markers, phosphorylation of Akt, and expression of insulin-like growth factor within the skeletal muscle are reduced in R3hdml KO mice compared to control mice. Expression of R3hdml increases during muscle regeneration in response to cardiotoxin (CTX)-induced muscle injury. Recovery of handgrip strength after CTX injection was significantly impaired in R3hdml KO mice, which is rescued by R3hdml. Our results indicate that R3hdml is required for skeletal muscle development, regeneration, and, in particular, satellite cell proliferation and differentiation.

平成24年度新潟大学保健学科国際保健学海外派遣研修プログラムにおいて，新潟大学保健学科学生９人（看護学専攻３年生３人，１年生３人；検査技術科学専攻３年生１人，１年生２人；引率教員２人）が，2013年３月11日㈪～19日㈫の日程で，カナダ・オンタリオ州にあるマクマスター大学，モホークカレッジ，ミチナー研究所を訪問し，カナダの保健医療や医療専門職の状況，そして，グローバルヘルスの実践者としてのあり方を学んだ。この研修によって，学び，感じたことをまとめた学生の研修レポートを紹介する。, Nine students of School of Health Sciences, Faculty of Medicine, Niigata University visited McMaster University, Mohawk College and Michener Institute to learn health sciences and culture in Canada from 11th to 19th of March 2013. In this short visit training program on global health sciences they were trained by taking lectures on current status of health care and medical systems in Canada, and taking a close look at educational scenes and workplaces of each professional field. They also observed the tri-field linkage and association of health services, medical services and welfare services. In social programs, the students well communicated with Canadian people in English and made effort to understand the culture of Canada. Student reports of what they have learned and felt in the short visit to Canada are shown.

Electrochemical reduction of alkyl mesylates was successfully carried out by using an undivided cell equipped with a Pt cathode and an Mg anode in the presence of biphenyl and t-BuOH. The reaction could proceed efficiently under mild conditions to give the corresponding alkanes in moderate to good yields. This procedure could also be applicable to chemoselective reduction of mesylates having functional groups such as epoxide, olefin, acetal, hydroxy, or cyano groups.

Electrochemical reduction of alkyl mesylates was successfully carried out by using an undivided cell equipped with a Pt cathode and an Mg anode in the presence of biphenyl and t-BuOH. The reaction could proceed efficiently under mild conditions to give the corresponding alkanes in moderate to good yields. This procedure could also be applicable to chemoselective reduction of mesylates having functional groups such as epoxide, olefin, acetal, hydroxy, or cyano groups.