Bohand X, Grippi R, Lefeuvre L, Le Garlantezec P, Aupée O, Simon L
Service de pharmacie hospitalière, Hôpital d'Instruction des Armées Percy, Clamart, France.
J Pharm Belg. 2008 Sep;63(3):73-7.
Many dispensing errors occur in hospital pharmacies and can harm patients if they are not intercepted. The aim of this study was to determine the incidence and the primary types of medication dispensing errors at a French military hospital.
The check of unit dose medication cassettes was performed by nurses. From February 2007 to April 2007, detected dispensing errors were systematically recorded and classified into 6 categories: unauthorized drug, wrong dosage-form, improper dose, omission, wrong time, and deteriorated drug errors. The overall error rate was calculated.
During the study, 5112 medication cassettes were checked. 106 dispensing errors have been detected by nurses for a total of 45,573 filled (n=45,518) and omitted (n=55) unit doses. An overall error rate of 0.23% was found. There were approximately 0.02 detected dispensing errors per medication cassette. The most common error types were omission errors (n=55, 51.88%) and improper dose errors (n=30, 28.30%).
DISCUSSION-CONCLUSION: The results of this study showed that a check performed by nurses after the dispensing process is necessary to detect the dispensing errors. Many causes may explain the occurrence of dispensing errors and must be corrected. Because some dispensing errors may remain undetected, there is a requirement to develop strategies in order to reduce or eliminate these errors, such as the implementation of a computerized prescribing system. The pharmacy staff is widely involved in this duty.
医院药房会发生许多调配差错，若未被拦截则可能伤害患者。本研究的目的是确定一家法国军队医院的用药调配差错发生率及主要类型。
护士对单位剂量药盒进行检查。在2007年2月至2007年4月期间，对检测到的调配差错进行系统记录，并分为6类：未授权药品、剂型错误、剂量不当、遗漏、时间错误和药品变质差错。计算总体差错率。
在研究期间，共检查了5112个药盒。护士检测到106起调配差错，涉及总共45573剂已配发（n = 45518）和遗漏（n = 55）的单位剂量。总体差错率为0.23%。每个药盒大约检测到0.02起调配差错。最常见的差错类型是遗漏差错（n = 55，51.88%）和剂量不当差错（n = 30，28.30%）。
讨论 - 结论：本研究结果表明，调配过程后由护士进行检查对于检测调配差错是必要的。许多原因可解释调配差错的发生，必须加以纠正。由于一些调配差错可能未被发现，因此需要制定策略以减少或消除这些差错，例如实施计算机化处方系统。药房工作人员广泛参与此项工作。
