Development of diffuse alveolar damage after initiation of Nijutsuto

Patient safety incident reports related to traditional Japanese Kampo medicines: medication errors and adverse drug events in a university hospital for a ten-year period

BACKGROUND

Kampo medicine is traditional Japanese medicine, which originated in ancient traditional Chinese medicine, but was introduced and developed uniquely in Japan. Today, Kampo medicines are integrated into the Japanese national health care system. Incident reporting systems are currently being widely used to collect information about patient safety incidents that occur in hospitals. However, no investigations have been conducted regarding patient safety incident reports related to Kampo medicines. The aim of this study was to survey and analyse incident reports related to Kampo medicines in a Japanese university hospital to improve future patient safety.

METHODS

We selected incident reports related to Kampo medicines filed in Toyama University Hospital from May 2007 to April 2017, and investigated them in terms of medication errors and adverse drug events.

RESULTS

Out of 21,324 total incident reports filed in the 10-year survey period, we discovered 108 Kampo medicine-related incident reports. However, five cases were redundantly reported; thus, the number of actual incidents was 103. Of those, 99 incidents were classified as medication errors (77 administration errors, 15 dispensing errors, and 7 prescribing errors), and four were adverse drug events, namely Kampo medicine-induced interstitial pneumonia. The Kampo medicine (crude drug) that was thought to induce interstitial pneumonia in all four cases was Scutellariae Radix, which is consistent with past reports. According to the incident severity classification system recommended by the National University Hospital Council of Japan, of the 99 medication errors, 10 incidents were classified as level 0 (an error occurred, but the patient was not affected) and 89 incidents were level 1 (an error occurred that affected the patient, but did not cause harm). Of the four adverse drug events, two incidents were classified as level 2 (patient was transiently harmed, but required no treatment), and two incidents were level 3b (patient was transiently harmed and required substantial treatment).

CONCLUSIONS

There are many patient safety issues related to Kampo medicines. Patient safety awareness should be raised to prevent medication errors, especially administration errors, and adverse drug events in Kampo medicine.

Development of diffuse alveolar damage after initiation of Nijutsuto

Chinese traditional medicine, Nijutsuto, is used to treat patients with frozen shoulder and osteoarthritis. Herbal medicine is often linked to the development of interstitial lung disease. An 83‐year‐old Japanese man with osteoarthritis who was on Nijutsuto was admitted to our hospital with dyspnoea and severe cough after 2 weeks from initiation of Nijutsuto. A chest computed tomography scan on admission showed diffuse ground glass opacity with traction bronchiectasis. Thus, he was diagnosed with Nijutsuto‐induced interstitial lung disease, and was treated with a high dose of methylprednisolone and cyclophosphamide. However, the patient died of respiratory failure 2 weeks after admission. The patient was definitively diagnosed with diffuse alveolar damage by pathological autopsy. Nijutsuto contains Radix Scutellariae, which is considered to be the cause of interstitial lung disease. Chinese traditional medicine containing both Radix Scutellariae and Licorice should be carefully used because of its potential role in the development of diffuse alveolar damage.