Tsuji Toshikazu, Nagata Kenichiro, Sasaki Keiichi, Matsukane Ryosuke, Ishida Shigeru, Kawashiri Takehiro, Suetsugu Kimitaka, Watanabe Hiroyuki, Hirota Takeshi, Ieiri Ichiro
Department of Pharmacy, Kyushu University Hospital, Fukuoka, Japan.
Clinical Pharmacy Education Center, Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan.
J Pharm Health Care Sci. 2022 Sep 1;8(1):23. doi: 10.1186/s40780-022-00254-x.
Pharmacists must understand the mechanisms by which dispensing errors occur and take appropriate preventive measures. In this study, the gaze movements of pharmacists were analyzed using an eye-tracking method, to elucidate the thinking process of pharmacists when identifying target drugs and avoiding dispensing errors.
We prepared verification slides and projected them on a large screen. Each slide comprised a drug rack area and a prescription area; the former consisted of a grid-like layout with 55 drugs and the latter displayed dispensing information (drug name, drug usage, location number, and total amount). Twelve pharmacists participated in the study, and three single-type drugs and six double-type drugs were used as target drugs. We analyzed the pharmacists' method of identifying the target drugs, the mechanisms by which errors occurred, and the usefulness of drug photographs using the error-induction (-) /photo (+), error-induction (+) / (+), and error-induction (+) /photo (-) models.
Visual invasion by non-target drugs was found to have an effect on the subsequent occurrence of dispensing errors. In addition, when using error-induction models, the rate of dispensing error was 2.8 and 11.1% for the photo (+) and photo (-) models, respectively. Furthermore, based on the analysis of eight pharmacists who dispensed drugs without errors, it was clear that additional confirmation of "drug name" was required to accurately identify the target drug in the photo (+) model; additionally, that of "location number" was required to pinpoint directly the position of target drug in the photo (-) model.
By analyzing the gaze movements of pharmacists using the eye-tracking method, we clarified pharmacists' thinking process which was required to avoid dispensing errors in a complicated environment and proved the usefulness of drug photographs in terms of both reducing the complexity of the dispensing process and the risk of dispensing errors. Effective measures to prevent dispensing errors include ensuring non-adjacent placement of double-type drugs and utilization of their image information.
药剂师必须了解调配错误发生的机制，并采取适当的预防措施。在本研究中，采用眼动追踪方法分析药剂师的注视运动，以阐明药剂师在识别目标药物和避免调配错误时的思维过程。
我们准备了验证幻灯片并将其投影到大屏幕上。每张幻灯片包括一个药架区域和一个处方区域；前者由一个有55种药物的网格状布局组成，后者显示调配信息（药物名称、用法、位置编号和总量）。12名药剂师参与了该研究，使用三种单一类型药物和六种双类型药物作为目标药物。我们使用错误诱导（-）/照片（+）、错误诱导（+）/（+）和错误诱导（+）/照片（-）模型分析了药剂师识别目标药物的方法、错误发生的机制以及药物照片的有用性。
发现非目标药物的视觉干扰对随后调配错误的发生有影响。此外，在使用错误诱导模型时，照片（+）模型和照片（-）模型的调配错误率分别为2.8%和11.1%。此外，通过对八名无错误调配药物的药剂师的分析，很明显在照片（+）模型中准确识别目标药物需要额外确认“药物名称”；此外，在照片（-）模型中直接确定目标药物的位置需要确认“位置编号”。
通过使用眼动追踪方法分析药剂师的注视运动，我们阐明了在复杂环境中避免调配错误所需的药剂师思维过程，并证明了药物照片在降低调配过程复杂性和调配错误风险方面的有用性。预防调配错误的有效措施包括确保双类型药物不相邻放置并利用其图像信息。
