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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 wrong-patient medication errors. These errors were caused by three conditions: (1) where two patients/drugs were listed next to one another, (2) where two patients’ last names/drugs’ names were the same, and (3) where the patient/drug/CPOE screen in front of the staff involved was believed to be the correct one. Additionally, these errors also involved insufficient confirmation, which led to failure to detect and correct the mismatch occurrences.Conclusion: Based on our study, we propose a new definition of wrong-patient medication errors: they consisted of choosing a wrong target and insufficient confirmation. We will investigate other types of wrong-patient errors to apply this definition.Keywords: wrong-patient error, medication error, web-based incident reporting system, computerized physician order entry, human error

Intraoperative computerized tomographic (CT) scan findings in two cases during resection of glial tumour are described. These intraoperative CT images were obtained by an exclusively developed operating CT scanner system for use in the operating room. Repeated intraoperative CT scans taken during tumour removal showed shift of the brain including central structures and displacement of the cortical subarachnoid space in both cases. With contrast medium, the edge of the surrounding brain after resection was enhanced and a round enhanced area was observed in distant white matter. The distant enhancement, which we call ‘remote enhancement probably suggests damage to the blood-brain barrier due to surgical manoeuvre. [Neurol Res 1994; 16: 265-267]

The high definition television (HDTV) system is introduced to microneurosurgery. Five cases with intracranial lesions: three cerebral aneurysms (giant aneurysms of the anterior communicating artery and internal carotid artery; aneurysm of the basilar artery), one acoustic neurinoma and one skull base meningioma, were operated on under the microscope using the HDTV system. The surgical procedures of each case were relayed and recorded by the system. In two of the five cases, we used two sets of HDTV system to produce stereoscopic projection. The HDTV system provided us with images of superior quality with a distinctly greater resolution than ordinary video systems.