- 期刊
利用更改藥名標示來降低調劑錯誤率之成效評估
Outcomes of Changing Medication Labeling to Reduce Dispensing Errors
摘要
Many dispensing errors occur in the hospital pharmacy and these can endanger patients. Therefore, setting prevention approaches for dispensing error is urgent. To examine the type and reasons for dispensing errors collected via intranet spontaneous reporting system and to evaluate the efforts implemented to reduce overall medication-related errors. Modifications of the medication labeling on dispensing sheet and package were made: 1. Trade names were used as the identification marker. 2. Tall man letters were applied in a variety of visual presentations of drug names. 3. Special instructions (e.g. high, intermediate and low) were placed directly behind the medication name. Dispensing errors collected from the pre- and post-change periods of Jan to Oct. 2008 and Jan. to Oct 2009, respectively, were analyzed. The total dispensed medications during the pre- and post-change periods were 3,575,135 and 4,500,659 respectively. The number of errors reported for the pre- and post-change periods were 2448 (0.068%) and 4839 (0.11%). Of these incidents, dispensing errors occurred at a rate of 0.005% and 0.0023%, and near miss occurred at a rate of 0.063% and 0.1%, respectively, for the pre- and post-change periods. The incidence of errors associated with similarly package drug labels was similar (5.7% vs.5.8%), however, differences were found in errors associated with look-alike medication name (18.4% vs.17%; p=0.25), similar name with different dosages (14% vs. 6.5%; p＜0.001) and similar name with different dosage forms (7.8% vs. 3.5%; p＜0.001) for the two periods. It was also found that up to 98% of dispensing errors can be intercepted if a double check is conducted. Proactive assessment of potential for medication errors can reduce the frequency and consequences of errors. Progress is being made on preventing confusing names, labels, and packages from making it to pharmacy shelves and hospital wards in the first place, and computerized order entry and bar coding system should help to decrease dispensing errors in the future.
並列摘要
Many dispensing errors occur in the hospital pharmacy and these can endanger patients. Therefore, setting prevention approaches for dispensing error is urgent. To examine the type and reasons for dispensing errors collected via intranet spontaneous reporting system and to evaluate the efforts implemented to reduce overall medication-related errors. Modifications of the medication labeling on dispensing sheet and package were made: 1. Trade names were used as the identification marker. 2. Tall man letters were applied in a variety of visual presentations of drug names. 3. Special instructions (e.g. high, intermediate and low) were placed directly behind the medication name. Dispensing errors collected from the pre- and post-change periods of Jan to Oct. 2008 and Jan. to Oct 2009, respectively, were analyzed. The total dispensed medications during the pre- and post-change periods were 3,575,135 and 4,500,659 respectively. The number of errors reported for the pre- and post-change periods were 2448 (0.068%) and 4839 (0.11%). Of these incidents, dispensing errors occurred at a rate of 0.005% and 0.0023%, and near miss occurred at a rate of 0.063% and 0.1%, respectively, for the pre- and post-change periods. The incidence of errors associated with similarly package drug labels was similar (5.7% vs.5.8%), however, differences were found in errors associated with look-alike medication name (18.4% vs.17%; p=0.25), similar name with different dosages (14% vs. 6.5%; p＜0.001) and similar name with different dosage forms (7.8% vs. 3.5%; p＜0.001) for the two periods. It was also found that up to 98% of dispensing errors can be intercepted if a double check is conducted. Proactive assessment of potential for medication errors can reduce the frequency and consequences of errors. Progress is being made on preventing confusing names, labels, and packages from making it to pharmacy shelves and hospital wards in the first place, and computerized order entry and bar coding system should help to decrease dispensing errors in the future.