Tsuji Toshikazu, Nagata Kenichiro, Kawashiri Takehiro, Yamada Takaaki, Irisa Toshihiro, Murakami Yuko, Kanaya Akiko, Egashira Nobuaki, Masuda Satohiro
Department of Pharmacy, Kyushu University Hospital.
Yakugaku Zasshi. 2016;136(11):1573-1584. doi: 10.1248/yakushi.16-00175.
There are many reports regarding various medical institutions' attempts at the prevention of dispensing errors. However, the relationship between occurrence timing of dispensing errors and subsequent danger to patients has not been studied under the situation according to the classification of drugs by efficacy. Therefore, we analyzed the relationship between position and time regarding the occurrence of dispensing errors. Furthermore, we investigated the relationship between occurrence timing of them and danger to patients. In this study, dispensing errors and incidents in three categories (drug name errors, drug strength errors, drug count errors) were classified into two groups in terms of its drug efficacy (efficacy similarity (-) group, efficacy similarity (+) group), into three classes in terms of the occurrence timing of dispensing errors (initial phase errors, middle phase errors, final phase errors). Then, the rates of damage shifting from "dispensing errors" to "damage to patients" were compared as an index of danger between two groups and among three classes. Consequently, the rate of damage in "efficacy similarity (-) group" was significantly higher than that in "efficacy similarity (+) group". Furthermore, the rate of damage is the highest in "initial phase errors", the lowest in "final phase errors" among three classes. From the results of this study, it became clear that the earlier the timing of dispensing errors occurs, the more severe the damage to patients becomes.
关于各类医疗机构预防调配差错的尝试有诸多报道。然而，在根据药物疗效进行分类的情况下，调配差错的发生时间与随后对患者的危险之间的关系尚未得到研究。因此，我们分析了调配差错发生的位置与时间之间的关系。此外，我们还研究了调配差错的发生时间与对患者的危险之间的关系。在本研究中，将调配差错及三类事件（药名差错、药物浓度差错、药品数量差错）根据药物疗效分为两组（疗效相似性（-）组、疗效相似性（+）组），根据调配差错的发生时间分为三个阶段（初始阶段差错、中间阶段差错、最终阶段差错）。然后，将从“调配差错”转变为“对患者的损害”的损害发生率作为危险指标，在两组之间以及三个阶段之间进行比较。结果，“疗效相似性（-）组”的损害发生率显著高于“疗效相似性（+）组”。此外，在三个阶段中，损害发生率在“初始阶段差错”中最高，在“最终阶段差错”中最低。从本研究结果可以明确，调配差错发生的时间越早，对患者的损害就越严重。
