Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromso, Norway.
Hospital Pharmacy of North Norway Trust, Tromso, Norway.
BMJ Qual Saf. 2017 Oct;26(10):817-823. doi: 10.1136/bmjqs-2016-006422. Epub 2017 Apr 21.
Medication errors are frequent and may cause harm to patients and increase healthcare expenses.
To explore whether a new labelling influences time and errors when preparing medications in accordance with medication charts in an experimental setting.
We carried out an uncontrolled before and after study with 3 months inbetween experiments. Phase I used original labelling and phase II used new generic labelling. We set up an experimental medicine room, simulating a real-life setting. Twenty-five nurses and ten pharmacy technicians participated in the study. We asked them to prepare medications in accordance with medication charts, place packages on a desk and document the package prepared. We timed the operation. Participants were asked to prepare medications in accordance with as many charts as possible within 30 min.
Nurses prepared significantly more medication charts with the generic labelling compared with the original 3.3 versus 2.6 (p=0.009). Mean time per medication chart was significantly lower with the generic labelling 6.9 min/chart versus 8.5 min/chart (p<0.001). Pharmacy technicians were significantly faster than the nurses in both phase I (6.8 min/chart vs 9.5 min/chart; p<0.001) and phase II (6.1 min/chart vs 7.2 min/chart; p=0.013). The number of errors was low and not significantly different between the two labellings, with errors affecting 9.1% of charts in phase I versus 6.5% in phase II (p=0.5).
A new labelling of medication packages with prominent placement of the active substance(s) and strength(s) in the front of the medication package may reduce time for nurses when preparing medications, without increasing medication errors.
用药错误频繁发生,可能对患者造成伤害并增加医疗保健费用。
在实验环境中,探索新标签是否会影响根据用药图表准备药物的时间和错误。
我们进行了一项无对照的前后研究,实验之间间隔 3 个月。第一阶段使用原始标签,第二阶段使用新的通用标签。我们建立了一个实验药房,模拟真实环境。25 名护士和 10 名药剂师参与了这项研究。我们要求他们根据用药图表准备药物,将包装放在桌子上并记录准备好的包装。我们记录操作时间。参与者被要求在 30 分钟内尽可能多地根据图表准备药物。
与原始标签相比,护士使用通用标签准备的用药图表明显更多,分别为 3.3 份和 2.6 份(p=0.009)。每份图表的平均准备时间明显较低,使用通用标签为 6.9 分钟/份,而使用原始标签为 8.5 分钟/份(p<0.001)。药剂师在第一阶段和第二阶段都明显快于护士,分别为 6.8 分钟/份和 9.5 分钟/份(p<0.001)和 6.1 分钟/份和 7.2 分钟/份(p=0.013)。错误数量较低,两种标签之间没有显著差异,第一阶段有 9.1%的图表出现错误,第二阶段有 6.5%(p=0.5)。
药物包装的新标签将活性物质和强度突出放置在药物包装的前面,可能会减少护士准备药物的时间,而不会增加药物错误。