Johnson K B, Butta J K, Donohue P K, Glenn D J, Holtzman N A
Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
Pediatrics. 1996 Apr;97(4):481-5.
This study measures the incidence of discrepancies among written prescriptions, medication regimens transcribed onto patient discharge instruction sheets (DCIs), and labels on medications dispensed by community pharmacies after discharge of patients from an academic medical center.
During a 2-month study period, we collected copies of prescriptions and DCIs. We also called care givers after discharge and asked them to read the medication labels that were filled from discharge prescriptions. Care givers were also asked whether they received instruction from community pharmacies.
Data were collected on 335 prescriptions for 192 patients. Differences among the prescriptions, DCIs, and medication labels were found for 40 (12%) of the medications prescribed at discharge, representing 19% of the patients studied. Nineteen prescriptions had prescriber errors in dosing frequencies or dosage formulations. Three prescriptions were filled with different medication concentrations or strengths than requested. Prescriptions were altered by the community pharmacists for unexplained reasons in 6 cases, whereas the DCIs and original prescriptions differed in 12 cases. Only 44% of families were counseled about proper medication administration by their pharmacists.
A potential for medication errors exists when pediatric patients are discharged with unfilled prescriptions. The potential may be worsened when discharge instructions are created from a prescription rather than from the label of a dispensed medication. Educational and risk-management efforts should emphasize the importance of writing complete, legible prescriptions and consulting appropriate reference materials to ensure that dose formulations and guidelines are accurate. Whenever possible, prescriptions should be filled before patients are discharged, so that the dispensed medications can be reviewed, and health care providers can provide accurate discharge instructions.
本研究旨在衡量学术医疗中心患者出院后，书面处方、转录到患者出院指导单（DCI）上的用药方案以及社区药房配发药品标签之间差异的发生率。
在为期2个月的研究期间，我们收集了处方和DCI的副本。我们还在患者出院后致电护理人员，要求他们阅读出院处方所配发药品的标签。护理人员还被问及是否从社区药房获得了指导。
收集了192名患者的335份处方数据。出院时所开处方的40种（12%）药物在处方、DCI和药品标签之间存在差异，占所研究患者的19%。19份处方存在开方者在给药频率或剂型方面的错误。3份处方所配发的药物浓度或强度与要求的不同。6例中社区药剂师出于不明原因更改了处方，而12例中DCI与原始处方不同。只有44%的家庭从药剂师那里得到了正确用药的指导。
儿科患者出院时带有未配药的处方存在用药错误的可能性。当出院指导依据处方而非所配发药品的标签制定时，这种可能性可能会加剧。教育和风险管理工作应强调开具完整、清晰处方以及查阅适当参考资料以确保剂量剂型和指南准确无误的重要性。只要有可能，应在患者出院前配好处方，以便对所配发的药物进行审核，并且医疗保健提供者能够提供准确的出院指导。
