Oswald Scott, Caldwell Richard
Stanford Hospital and Clinics, Stanford, CA, USA.
Am J Health Syst Pharm. 2007 Jul 1;64(13):1427-31. doi: 10.2146/ajhp060313.
A study was conducted to determine filling and dispensing error rates before and after the implementation of an automated pharmacy carousel system (APCS).
The study was conducted in a 613-bed acute and tertiary care university hospital. Before the implementation of the APCS, filling and dispensing rates were recorded during October through November 2004 and January 2005. Postimplementation data were collected during May through June 2006. Errors were recorded in three areas of pharmacy operations: first-dose or missing medication fill, automated dispensing cabinet fill, and interdepartmental request fill. A filling error was defined as an error caught by a pharmacist during the verification step. A dispensing error was defined as an error caught by a pharmacist observer after verification by the pharmacist.
Before implementation of the APCS, 422 first-dose or missing medication orders were observed between October 2004 and January 2005. Independent data collected in December 2005, approximately six weeks after the introduction of the APCS, found that filling and error rates had increased. The filling rate for automated dispensing cabinets was associated with the largest decrease in errors. Filling and dispensing error rates had decreased by December 2005. In terms of interdepartmental request fill, no dispensing errors were noted in 123 clinic orders dispensed before the implementation of the APCS. One dispensing error out of 85 clinic orders was identified after implementation of the APCS.
The implementation of an APCS at a university hospital decreased medication filling errors related to automated cabinets only and did not affect other filling and dispensing errors.
开展一项研究以确定自动药房旋转木马系统（APCS）实施前后的调配和发药错误率。
该研究在一家拥有613张床位的急性病和三级护理大学医院进行。在APCS实施前，于2004年10月至11月以及2005年1月记录调配和发药率。实施后的数据于2006年5月至6月收集。在药房操作的三个领域记录错误：首剂或漏发药品调配、自动发药柜调配以及部门间申请调配。调配错误定义为药剂师在核查步骤中发现的错误。发药错误定义为药剂师核查后由药剂师观察员发现的错误。
在APCS实施前，2004年10月至2005年1月期间观察到422例首剂或漏发药品医嘱。在2005年12月（APCS引入后约六周）收集的独立数据发现，调配率和错误率有所增加。自动发药柜的调配率与错误率的最大降幅相关。到2005年12月，调配和发药错误率有所下降。就部门间申请调配而言，在APCS实施前调配的123份门诊医嘱中未发现发药错误。APCS实施后，在85份门诊医嘱中发现1例发药错误。
大学医院实施APCS仅降低了与自动发药柜相关的药品调配错误，并未影响其他调配和发药错误。
