Bohand Xavier, Aupée Olivier, Le Garlantezec Patrick, Mullot Hélène, Lefeuvre Leslie, Simon Laurent
H I A PERCY, Service Pharmacie Hospitaliere, 101 Avenue Henri Barbusse, 92141, Clamart Cedex, France.
Pharm World Sci. 2009 Aug;31(4):432-438. doi: 10.1007/s11096-009-9290-3. Epub 2009 Mar 21.
To determine the rate and the primary types of medication dispensing errors detected by pharmacists during implementation of a unit dose drug dispensing system.
The central pharmacy at the Percy French military hospital (France).
The check of the unit dose medication cassettes was performed by pharmacists to identify dispensing errors before delivering to the care units. From April 2006 to December 2006, detected errors were corrected and recorded into seven categories: unauthorized drug, wrong dosage-form, improper dose, omission, wrong time, deteriorated drug, and wrong patient errors.
Dispensing error rate, calculated by dividing the total of detected errors by the total of filled and omitted doses; classification of recorded dispensing errors.
During the study, 9,719 unit dose medication cassettes were filled by pharmacy technicians. Pharmacists detected 706 errors for a total of 88,609 filled and omitted unit doses. An overall error rate of 0.80% was found. There were approximately 0.07 detected dispensing errors per medication cassette. The most common error types were improper dose errors (n = 265, 37.5%) and omission errors (n = 186, 26.3%). Many causes may probably explain the occurrence of dispensing errors, including communication failures, problems related to drug labeling or packaging, distractions, interruptions, heavy workload, and difficulties in reading handwriting prescriptions.
The results showed that a wide range of errors occurred during the dispensing process. A check performed after the initial medication selection is also necessary to detect and correct dispensing errors. In order to decrease the occurrence of dispensing errors, some practical measures have been implemented in the central pharmacy. But because some dispensing errors may remain undetected, there is a requirement to develop other strategies that reduce or eliminate these errors. The pharmacy staff is widely involved in this duty.
确定在实施单剂量配药系统期间药剂师检测到的配药错误率及主要类型。
法国珀西·弗伦奇军事医院的中心药房。
药剂师在将单剂量药盒发放至护理单元之前进行检查，以识别配药错误。2006年4月至2006年12月，对检测到的错误进行纠正并记录为七类：未授权用药、剂型错误、剂量不当、遗漏、时间错误、药品变质及患者错误。
配药错误率，通过将检测到的错误总数除以已配药和遗漏剂量总数计算得出；记录的配药错误分类。
研究期间，药房技术人员共配了9719个单剂量药盒。药剂师检测到706个错误，涉及88609个已配药和遗漏的单剂量。总体错误率为0.80%。每个药盒约检测到0.07个配药错误。最常见的错误类型是剂量不当错误（n = 265，37.5%）和遗漏错误（n = 186，26.3%）。许多原因可能解释配药错误的发生，包括沟通失误、与药品标签或包装相关的问题、分心、干扰、工作量大以及阅读手写处方困难。
结果表明，配药过程中发生了多种错误。在最初选药后进行检查对于检测和纠正配药错误也是必要的。为了减少配药错误的发生，中心药房已实施了一些实际措施。但由于一些配药错误可能未被发现，需要制定其他策略来减少或消除这些错误。药房工作人员广泛参与此项工作。
