Pang F, Grant J A
Am J Hosp Pharm. 1975 Nov;32(11):1121-3.
The reasons for missing medications in a centralized unit dose system were studied, and means of improving the situation were recommended. Reasons for missing medications included: insufficient or incorrect medications dispensed by the pharmacy, differences in interpretations of orders by pharmacists and nurses, administration of extra medication or incorrect doses, waste of medication, administration of medication to patients other than for whom it was dispensed, delivery to wrong nursing unit, pilferage, and requests by nurses for medication before the orders were received by the pharmacy. A procedure for checking medications in unit dose carts by pharmacy and nursing personnel was implemented. Before this procedure, the rate of missing medications was 0.93% of the doses dispensed; after the procedure, the rate was 0.33%. Other recommendations designed to prevent missing medications in this unit dose system are presented.
对集中单剂量系统中药物遗漏的原因进行了研究，并提出了改善这种情况的方法。药物遗漏的原因包括：药房发放的药物不足或错误、药剂师和护士对医嘱的理解差异、额外药物或错误剂量的给药、药物浪费、将药物给非指定患者使用、送到错误的护理单元、偷窃以及护士在药房收到医嘱之前就索要药物。实施了一项药房和护理人员检查单剂量推车中药物的程序。在该程序实施之前，药物遗漏率为发放剂量的0.93%；实施该程序之后，遗漏率为0.33%。还提出了旨在防止该单剂量系统中药物遗漏的其他建议。
