Fahimi Fanak, Abbasi Nazari Mohammad, Abrishami Ramin, Sistanizad Mohammad, Mazidi Talya, Faghihi Toktam, Soltani Rasoul, Baniasadi Shadi
Clinical Pharmacy Department, School of Pharmacy, Shahid Beheshti University, M.C., Tehran, Iran.
Arch Iran Med. 2009 Mar;12(2):173-5.
Medication errors are among the most common medical errors in the hospitals. Transcription error is a specific type of medication errors and is due to data entry error that is commonly made by the human operators. This study was designed to detect transcription errors in a teaching hospital in Tehran. Direct observational method was used in this study. Error was defined as any deviation in transcribing medication order from the previous step (order on the order sheet, administration nursing note and/or cardex, documentation of the order in the pharmacy database). A total of 287 charts with 558 opportunities for error were reviewed. Of those opportunities for error 167 (29.9%) resulted in an error. Omission (the patient did not receive the medication that was ordered) was the highest (52%) transcription error type seen in this study. The evaluation clearly showed that errors at transcription stage were not infrequent. To cut these errors down we suggest implementation of surveillance systems, which might help to decrease medication errors.
用药错误是医院中最常见的医疗错误之一。转录错误是用药错误的一种特定类型，是由人工操作员常见的数据录入错误导致的。本研究旨在检测德黑兰一家教学医院的转录错误。本研究采用直接观察法。错误被定义为在转录用药医嘱时与上一步（医嘱单上的医嘱、护理给药记录和/或病历，药房数据库中的医嘱记录）存在任何偏差。共审查了287份病历，有558次出错机会。在这些出错机会中，167次（29.9%）导致了错误。遗漏（患者未接受所开的药物）是本研究中出现的最高比例（52%）的转录错误类型。评估清楚地表明，转录阶段的错误并不罕见。为了减少这些错误，我们建议实施监测系统，这可能有助于减少用药错误。
