Peterson G M, Wu M S, Bergin J K
Tasmanian School of Pharmacy, Faculty of Health Science, University of Tasmania, Hobart, Australia.
J Clin Pharm Ther. 1999 Feb;24(1):57-71. doi: 10.1046/j.1365-2710.1999.00199.x.
To assess the attitudes of pharmacists towards the issue of dispensing errors.
A postal survey was undertaken among all Tasmanian-registered pharmacists residing in Australia. The anonymous questionnaire sought opinions on whether the risk of dispensing errors and the actual numbers of errors are increasing, the major factors contributing to the occurrence of dispensing errors, factors that can best minimize the risk of dispensing errors, the number of prescription items that one pharmacist can safely dispense in a day and whether Australia should have a regulatory maximum dispensing load, and an estimation of the number of recent errors at the pharmacist's workplace.
Completed questionnaires were received from 209 pharmacists (50% response rate). Most pharmacists (82%) believed that the risk of dispensing errors is increasing. The principal contributing factors nominated were: high prescription volumes, pharmacist fatigue, pharmacist overwork, interruptions to dispensing, and similar or confusing drug names. The main factors identified as being important in reducing the risk of dispensing errors were: having mechanisms for checking dispensing procedures, having a systematic dispensing workflow, checking the original prescription (duplicate) when dispensing repeats, improving the packaging and labelling of drug products, having drug names that are distinctive, counselling patients at the time of supply, keeping one's knowledge of drugs up-to-date, avoiding interruptions, reducing workloads on pharmacists, improving doctors' handwriting, and privacy when counselling patients. Most pharmacists (72%) stated that they were aware of dispensing errors that had left the pharmacy undetected, in their place of practice during the past 6 months. The median number of such dispensing errors that they were aware of was three. A median of 150 was nominated as the maximum number of prescription items that can be safely dispensed per 9-h day (i.e. 17 items per hour) by or in the presence of one pharmacist. Most pharmacists (58%) stated that there should be a regulatory guideline for the safe dispensing load in Australia.
Dispensing errors are occurring in numbers well above reports to regulatory authorities or professional indemnity insurance companies, and seem to be accepted as part of practice. High prescription volumes, pharmacist fatigue and overwork appear to be important factors. The profession needs to be proactive and standards must be set appropriately high (i.e. zero error tolerance).
评估药剂师对调配差错问题的态度。
对居住在澳大利亚的所有塔斯马尼亚注册药剂师进行了邮寄调查。这份匿名问卷征求了以下方面的意见：调配差错的风险及实际差错数量是否在增加、导致调配差错发生的主要因素、能最大程度降低调配差错风险的因素、一名药剂师一天可安全调配的处方数量、澳大利亚是否应设定监管性的最大调配量，以及对药剂师工作场所近期差错数量的估计。
共收到209名药剂师填写的问卷（回复率为50%）。大多数药剂师（82%）认为调配差错的风险在增加。被提名的主要促成因素有：处方量高、药剂师疲劳、药剂师工作过度、调配过程中的干扰以及相似或易混淆的药品名称。被确定为对降低调配差错风险重要的主要因素有：具备检查调配程序的机制、拥有系统的调配工作流程、在调配重复处方时检查原始处方（副本）、改进药品包装和标签、使用独特的药品名称、在发药时为患者提供咨询、保持对药品知识的更新、避免干扰、减轻药剂师的工作量、改进医生的字迹以及在为患者提供咨询时保护隐私。大多数药剂师（72%）表示，在过去6个月里，他们在自己的工作场所知晓有未被药房发现的调配差错。他们知晓的此类调配差错的中位数为3起。每9小时工作日（即每小时17项）一名药剂师或在其在场情况下可安全调配的处方最大数量的中位数被提名为150项。大多数药剂师（58%）表示，澳大利亚应该有关于安全调配量的监管指南。
调配差错的发生数量远高于向监管机构或专业责任保险公司报告的数量，并且似乎被视为工作的一部分而被接受。高处方量、药剂师疲劳和工作过度似乎是重要因素。该行业需要积极主动，必须将标准设定得足够高（即零差错容忍度）。
