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Patient safety promotion in community pharmacy based on the knowledge gained through adverse event reporting system

日程: 2016年1月21日

演者: 後 信
公益財団法人 日本医療機能評価機構 執行理事
Date:  21 January 2016

Presenter: Professor Shin Ushiro, Executive Board Member - Japan Council for Quality Health Care, Professor and Director, Division of Patient Safety, Kyushu University Hospital


Participants' Feedback


大西 晃二
"A proposal was put forward to stop carrying out out-patient drug audits where I work as our hospitals are small and only have a few pharmacists.  We decided to continue these audits without relying on dispensing pharmacies to improve the safety culture in our hospitals. After watching this webinar, I know we made the right decision."

Kouji Oonishi
Quality Manager


"This webinar was very beneficial as it introduced me to the issue of near-miss events in pharmacy.  I did not realise that this was also happening in other hospitals. I will be referring to Japan Council for Quality Health Care’s website for guidance on how to prevent this from happening and how to improve quality in healthcare.”

Momoko Asano
Section Head /Safety Manager

About the Webinar



Significantly frequent near-miss events are supposed to happen in community pharmacies. Japan Council for Quality Health Care (JQ) launched the project to collect and study near-miss event of community pharmacy in 2008. It is of note that 15% of cases are related to “Inquiry on prescription” while others are related to “Dispensing”. Inquiry is a vital function of a pharmacist in the provision of healthcare according to “Pharmacists Law”. It has been elucidated that errors could be corrected through the inquiry contributing to prevention of medical accident. In the webinar, the role of the community pharmacy is to be reviewed.

About the Presenter

後 信(うしろ しん)
(公財)日本医療機能評価機構 執行理事
九州大学病院医療安全管理部 教授・部長

Professor Shin Ushiro is Executive Board Member for Japan Council for Quality Health Care and Professor of the Division of Patient Safety Management- Kyushu University Hospital, Kyushu University Graduate School of Medicine. He currently is an ISQua Expert. He serves as a member on patient safety or clinical research in various scientific entities. His main theme is to promote patient safety based on lessons learned from intramural and/or nationwide adverse event (AE) reporting system. He has been engaged in nationwide AE reporting system for approximately ten years in JQ and crafted dozens of quarterly reports and monthly alerts.


ISQua Webinar_ Jan2016_Shin Ushiro

Fellowship Questions

1. 薬局ヒヤリ・ハット事例収集・分析事業で収集している事例の概要について誤っているものを選べ。

a. 調剤に関する事例が最も多い。
b. 疑義照会に関する事例は報告対象範囲に含まれていない。
c. 特定保健医療材料に関する事例の報告は少ない。
d. 医薬品の販売に関する事例の報告は少ない。

2. 薬局ヒヤリ・ハット事例収集・分析事業について正しいものを選べ。

a. 薬局で発生したエラーによる事例のみ収集している。
b. テーマ分析では、後発変更に関する事例や配合剤に関する事例を取り挙げている。
c. 参加薬局は、全国の薬局の約1割にあたる5,000軒程度である。
d. 毎年の報告件数は、1,000件程度である。

3. 薬局ヒヤリ・ハット事例収集・分析事業の成果について誤っているものを選べ。

a. 年報を作成している。
b. 薬局ヒヤリ・ハット分析表を作成している。
c. ホームページには報告事例の検索機能が備わっている。
d. ホームページで薬局毎に報告した件数と事例が一覧できる。