Kutsuma Nobuaki, Yamaura Katsunori, Hosaka Shigeru, Kasuga Kazuo, Koresawa Taketoshi, Nagamura Miho, Takayanagi Masayuki, Nemoto Eiichi, Ohshima Shigeru, Kobayashi Daisuke, Saito Yukiya
Asahi-Chozai Co., Ltd., Higashiohnari, Saitama, Japan.
Yakugaku Zasshi. 2007 Sep;127(9):1515-21. doi: 10.1248/yakushi.127.1515.
In this study, a survey was conducted to determine the rate of drug-dispensing errors with the use of medicine bags printed with photographs of prescribed medicines (hereafter "medicine bag") for a 6-week period from June 20 to July 31, 2005. During this period, 393928 prescriptions were filled in 127 medical facilities that use the medicine bag. The efficacy of the medicine bag in the prevention of drug-dispensing errors was investigated. A total of 6550 (1.66%) drug-dispensing errors were identified: 70.6% were identified at the inspecting stage; 27.4% at the providing medicine and information stage; and 2% after the medication was dispensed. The drug-dispensing errors identified in the inspecting and providing stages included a) using the wrong contents, b) dispensing the wrong drugs, c) missing drugs, d) calculation errors, e) weighing/measuring errors, and f) others. No significant difference was observed in the error rates; thus it was assumed that the type of error was not dependent on the stage at which dispensing errors was discovered. However, it was found that approximately 25% of errors at the providing stage were discovered as a result of the medicine bag. Errors of types a), b), and c) were often discovered because the photograph was printed on the medicine bag. Therefore it was assumed that the photographs contributed to the discovery of drug-dispensing errors.
在本研究中，于2005年6月20日至7月31日的6周期间进行了一项调查，以确定使用印有处方药照片的药袋（以下简称“药袋”）时的配药错误率。在此期间，127家使用该药袋的医疗机构共填写了393928张处方。对药袋在预防配药错误方面的效果进行了调查。共识别出6550例（1.66%）配药错误：70.6%在检查阶段被识别；27.4%在发药及提供信息阶段被识别；2%在药品配出后被识别。在检查和发药阶段识别出的配药错误包括：a）使用错误的内容物，b）配发错误的药品，c）漏发药品，d）计算错误，e）称重/测量错误，以及f）其他。未观察到错误率有显著差异；因此假定错误类型不取决于发现配药错误的阶段。然而，发现发药阶段约25%的错误是由于药袋而被发现的。a）、b）和c）类错误经常因药袋上印有照片而被发现。因此假定照片有助于发现配药错误。
