Chua Siew-Siang, Wong Ian C K, Edmondson Hilary, Allen Caroline, Chow Jean, Peacham Joanne, Hill Graham, Grantham Jenny
Centre for Paediatric Pharmacy Research, School of Pharmacy, University of London and the Institute of Child Health, University College London, London, United.
Drug Saf. 2003;26(11):803-13. doi: 10.2165/00002018-200326110-00005.
Medication errors can occur at the prescribing, transcription, dispensing and administration stage of drug therapy. However, publication of the Organisation with a Memory (OWAM) by the Department of Health in the UK has raised awareness of the need for pharmacies to collect information about dispensing errors and near misses, which occur within an organisation. Such information provides valuable insights into the vulnerabilities of dispensing procedures and identifies areas for improvement in dispensing systems The main aim of this study was to investigate the feasibility of a self-reporting system for dispensing errors and near misses in primary care (community) pharmacies. It was also to identify the types of errors or near misses commonly encountered in community pharmacies. A data collection form was designed and modified for use after a pilot study. Four community pharmacies volunteered to participate in this feasibility study. The data collection was conducted in two phases each of 4 weeks' duration. Any dispensing errors and near misses that occurred during the study periods were recorded by the pharmacy staff in a standard data collection form. A focus group discussion was held with the dispensing staff of participating pharmacies to identify and evaluate the feasibility of the reporting system. Out of a total of 51 357 items dispensed during the two phases of the study, 39 dispensing errors (0.08%) and 247 near misses (0.48%) were detected. The results show that near misses occurred six times more often than dispensing errors, indicating the importance of final checking in pharmacies. The most common types of dispensing errors or near misses appeared to be incorrect strength of medication, followed by incorrect drug, incorrect quantity, incorrect dosage form and incorrect label. Feedback during the focus group discussion indicated that the outcome of the self-reporting scheme was more important than the incidence of errors or near misses. Participating pharmacies also agreed that the self-reporting scheme used was feasible and they would continue using the scheme although some incentives would be helpful. The quantitative results of this study and the qualitative feedback from the participating pharmacies indicate that the self-reporting scheme used is practical and feasible.
用药错误可能发生在药物治疗的处方、转录、调配和给药阶段。然而，英国卫生部发布的《有记忆的组织》（OWAM）提高了人们对药房收集组织内部发生的调配错误和险些失误信息必要性的认识。此类信息为洞察调配程序的薄弱环节提供了宝贵见解，并确定了调配系统中需要改进的领域。本研究的主要目的是调查基层医疗（社区）药房用于报告调配错误和险些失误的自我报告系统的可行性。同时还要确定社区药房中常见的错误或险些失误类型。在一项预试验研究之后，设计并修改了一份数据收集表以供使用。四家社区药房自愿参与这项可行性研究。数据收集分两个阶段进行，每个阶段为期4周。药房工作人员在标准数据收集表中记录研究期间发生的任何调配错误和险些失误。与参与研究的药房调配人员进行了焦点小组讨论，以确定并评估报告系统的可行性。在研究的两个阶段共调配了51357项药品，发现了39起调配错误（0.08%）和247起险些失误（0.48%）。结果表明，险些失误的发生频率是调配错误的六倍，这表明药房最终检查的重要性。最常见的调配错误或险些失误类型似乎是药物强度错误，其次是药品错误、数量错误、剂型错误和标签错误。焦点小组讨论期间的反馈表明，自我报告方案的结果比错误或险些失误的发生率更重要。参与研究的药房也认为所使用的自我报告方案是可行的，尽管一些激励措施会有所帮助，但他们仍会继续使用该方案。本研究的定量结果以及参与研究的药房的定性反馈表明，所使用的自我报告方案是切实可行的。
