Beso Adnan, Franklin Bryony Dean, Barber Nick
Faculty of Pharmacy, University of Ljubljana, Slovenia.
Pharm World Sci. 2005 Jun;27(3):182-90. doi: 10.1007/s11096-004-2270-8.
To determine the frequency and types of dispensing errors identified both at the final check stage and outside of a UK hospital pharmacy, to explore the reasons why they occurred, and to make recommendations for their prevention.
A definition of a dispensing error and a classification system were developed. To study the frequency and types of errors, pharmacy staff recorded details of all errors identified at the final check stage during a two-week period; all errors identified outside of the department and reported during a one-year period were also recorded. During a separate six-week period, pharmacy staff making dispensing errors identified at the final check stage were interviewed to explore the causes; the findings were analysed using a model of human error.
Percentage of dispensed items for which one or more dispensing errors were identified at the final check stage; percentage for which an error was reported outside of the pharmacy department; the active failures, error producing conditions and latent conditions that result in dispensing errors occurring.
One or more dispensing errors were identified at the final check stage in 2.1% of 4849 dispensed items, and outside of the pharmacy department in 0.02% of 194,584 items. The majority of those identified at the final check stage involved slips in picking products, or mistakes in making assumptions about the products concerned. Factors contributing to the errors included labelling and storage of containers in the dispensary, interruptions and distractions, a culture where errors are seen as being inevitable, and reliance on others to identify and rectify errors.
Dispensing errors occur in about 2% of all dispensed items. About 1 in 100 of these is missed by the final check. The impact on dispensing errors of developments such as automated dispensing systems should be evaluated.
确定在英国医院药房的最终核对阶段及之外所识别出的调配差错的频率和类型，探究其发生原因，并提出预防建议。
制定了调配差错的定义和分类系统。为研究差错的频率和类型，药房工作人员记录了两周内最终核对阶段识别出的所有差错细节；还记录了该科室之外识别出并在一年内报告的所有差错。在一个单独的六周期间，对在最终核对阶段识别出有调配差错的药房工作人员进行访谈以探究原因；采用人因差错模型对结果进行分析。
在最终核对阶段识别出有一个或多个调配差错的调配药品的百分比；在药房科室之外报告有差错的百分比；导致调配差错发生的主动失误、差错产生条件和潜在条件。
在4849件调配药品中，2.1%在最终核对阶段被识别出有一个或多个调配差错，在194584件药品中，0.02%在药房科室之外被识别出有差错。在最终核对阶段识别出的差错大多数涉及取药时的失误，或对相关药品做出假设时的错误。导致差错的因素包括药房内容器的标签和储存、干扰和分心、认为差错不可避免的文化氛围，以及依赖他人识别和纠正差错。
所有调配药品中约2%会发生调配差错。其中约每100个中有1个在最终核对时被遗漏。应评估自动调配系统等发展对调配差错的影响。
