Department of Hospital Pharmacy, VU Medical Centre, Amsterdam, The Netherlands.
Int J Nurs Stud. 2011 Jul;48(7):791-7. doi: 10.1016/j.ijnurstu.2010.12.007. Epub 2011 Jan 17.
The medication cart can be filled using an automated system or a manual method and when using a manual method the medication can be arranged either by round time or by medication name. For the manual methods, it is hypothesized that the latter method would result in a lower frequency of medication administration errors because nurses are forced to read the medication labels, but evidence for this hypothesis is lacking.
The aim of this study was to compare the frequency of medication administration errors of two different manual medication cart filling methods, namely arranging medication by round time or by medication name.
A prospective, observational study with a before-after design.
Eighty-six patients who stayed on an orthopaedic ward in one university medical centre in the Netherlands were included.
Disguised observation was used to detect medication administration errors. The medication cart filling method in usual care was to fill the cart with medication arranged by round time. The intervention was the implementation of the second medication cart filling method, where the medication cart was filled by arranging medicines by their names. The primary outcome was the frequency of medication administrations with one or more error(s) after the intervention compared with before the intervention. The secondary outcome was the frequency of subtypes of medication administration errors.
After the intervention 170 of 740 (23.0%) medication administrations with one or more medication administration error(s) were observed compared to 114 of 589 (19.4%) before the intervention (odds ratio 1.24 [95% confidence interval 0.95-1.62]). The distribution of subtypes of medication administration errors before and after the intervention was statistically significantly different (p<0.001). Analysis of subtypes revealed more omissions and wrong time errors after the intervention than before the intervention. Unauthorized medication errors were detected more frequently before the intervention than after the intervention.
The frequency of medication administration errors with the medication cart filling method where the medication is arranged by name was not statistically significantly different compared to the medication cart filling method where the medication is arranged by round time.
药品车可以通过自动化系统或手动方法进行填充，而在使用手动方法时，药品可以按轮次或药品名称进行排列。对于手动方法，假设后者方法会导致用药错误的频率更低，因为护士必须阅读药品标签，但缺乏对此假设的证据。
本研究旨在比较两种不同的手动药品车填充方法（按轮次或药品名称排列药品）的用药错误频率。
前瞻性、观察性研究，采用前后设计。
荷兰一家大学医学中心骨科病房的 86 名患者被纳入研究。
伪装观察用于检测用药错误。常规护理中，药品车的填充方法是按轮次排列药品。干预措施是实施第二种药品车填充方法，即按药品名称排列药品车。主要结局是干预后与干预前相比，一次或多次用药错误的用药次数。次要结局是用药错误的亚型频率。
干预后观察到 740 次用药中有 170 次（23.0%）存在一次或多次用药错误，而干预前 589 次用药中有 114 次（19.4%）（比值比 1.24 [95%置信区间 0.95-1.62]）。干预前后用药错误亚型的分布存在统计学差异（p<0.001）。亚型分析显示，干预后漏用和错时错误的发生率高于干预前。未经授权的用药错误在干预前比干预后更频繁地被发现。
按名称排列药品的药品车填充方法与按轮次排列药品的方法相比，用药错误的频率没有统计学显著差异。
