The objective of the Project is to further promote medical safety by providing health professionals in pharmacies and the general public with relevant information as well as to share information useful to develop preventive measures by collecting and analyzing near-miss events from pharmacies and widely providing with the result of analysis.

Various healthcare professionals such as physicians, dentists, pharmacists and nurses are involved in the process of patient care and treatment.

Among the healthcare professionals, pharmacists have responsibilities to dispense and verify prescriptions and drugs and to give medication-related instruction to patients as "drug specialists."
Pharmacists are also involved in such activities as sales of over the counter (OTC) drugs and in-pharmacy formulations and providing information concerning these products at pharmacies. Pharmacists and registered sales clerks are therefore playing an important role in public healthcare by giving instruction and providing information on self-medication and other treatments to consumers.

Unexpected errors can be made at pharmacies just as at medical institutions and other corporations. In general, it has been said that pharmacies where serious accidents happen have usually experienced near-miss events that might have resulted in similar accidents in the past. It has also been said that twenty-nine non-serious, accidents coming after 300 near-miss events generally repeated before a single serious accident occurs. In the Project to Collect and Analyze Pharmaceutical Near-Miss Events, events with any of the following three categories are collected.

In the Project to Collect and Analyze Pharmaceutical Near-Miss Events, events with any of the following three categories are collected.

1. A medical error occurred or identified before the health care service was provided to the patient.
e.g. A wrong medication was prepared, and the error was identified before giving the medication to the patient. Later the correct  medication was prepared.

2. A medical error that did not affect the patient or required a minor procedure/treatment, which includes disinfection, poultice and  administration of analgesics.
e.g. A wrong medication was prepared and given to a patient, but the error was identified before the patient took the medication.

3. A medical error for which the consequence is unknown.
e.g. A drug with wrong indications (e.g., symptoms to be treated) from those the consumer desired was sold, but thereafter the  consumer could not be reached.

* In the Project, "health care service" is defined as any and/or all processes related to medical practice (including sales of OTC drugs).

Note:"Accidents" may or may not involve medical negligence.
Excerpted from “Partial Enforcement of the Ordinance to Partially Revise the Ordinance for Enforcement of the Health Service Act” (MHLW HPB Notification; September 21, 2004)

1. Background

2. Current status of near-miss events occurring

3. Objective

4. Features of dispensing at pharmacies

5. Examples of near-miss events occurred at pharmacies are released

Annual report

Pharmaceutical near-miss event analysis table