How Many Hospital Pharmacy Medication Dispensing Errors Go Undetected?

被引：70

作者：

Cina, Jennifer L. ^{[1
]}

Gandhi, Tejal K. ^{[2
]}

Churchill, William ^{[3
]}

Fanikos, John ^{[3
]}

McCrea, Michelle ^{[4
]}

Mitton, Patricia ^{[4
]}

Rothschild, Jeffrey M. ^{[5
]}

Featherstone, Erica ^{[4
]}

Keohane, Carol ^{[6
]}

Bates, David W. ^{[5
]}

Poon, Eric G. ^{[5
]}

机构：

[1] Brigham & Womens Hosp, 75 Francis St, Boston, MA 02115 USA

[2] Div Gen Med & Primary Care, Patient Safety, Boston, MA USA

[3] Div Gen Med & Primary Care, Pharm, Boston, MA USA

[4] Div Gen Med & Primary Care, Boston, MA USA

[5] Div Gen Med & Primary Care, Med, Boston, MA USA

[6] Ctr Excellence Patient Safety, Boston, MA USA

来源：

JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY | 2006年 / 32卷 / 02期

基金：

美国医疗保健研究与质量局;

关键词：

D O I：

10.1016/S1553-7250(06)32010-7

中图分类号：

R19 [保健组织与事业（卫生事业管理）];

学科分类号：

摘要：

Background: Hospital pharmacies dispense large numbers of medication doses for hospitalized patients. A study was conducted at an academic tertiary care hospital to characterize the incidence and severity of medication dispensing errors in a hospital pharmacy. Methods: Direct observation of dispensing processes was undertaken to determine presence of errors with review by a physician panel to determine severity. Results: A total of 140,755 medication doses filled by pharmacy technicians were observed during a seven-month period, and 3.6% (5,075) contained errors. The hospital pharmacist detected only 79% of these errors during routine verification; thus, 0.75% of doses filled would have left the pharmacy with undetected errors. Overall, 23.5% of undetected errors were potential adverse drug events (ADEs), of which 28% were serious and 0.8% were life threatening. The most common potential ADEs were incorrect medications (36%), incorrect strength (35%), and incorrect dosage form (21%). Discussion: Given the volume of medications dispensed, even a low rate of drug distribution process translates into a large number of errors with potential to harm patients. Pharmacy distribution systems require further process redesign to achieve the highest possible level of safety and reliability.

引用

页码：73 / 80

页数：8

共 23 条

[1]

Barker KN, 1962, AM J HOSP PHARM, V19, P360

[2] Using information technology to reduce rates of medication errors in hospitals [J].

Bates, DW .

BRITISH MEDICAL JOURNAL, 2000, 320 (7237) :788-791

[3] Patient risk factors for adverse drug events in hospitalized patients [J].

Bates, DW ;

Miller, EB ;

Cullen, DJ ;

Burdick, L ;

Williams, L ;

Laird, N ;

Petersen, LA ;

Small, SD ;

Sweitzer, BJ ;

Vander Vliet, M ;

Leape, LL .

ARCHIVES OF INTERNAL MEDICINE, 1999, 159 (21) :2553-2560

[4] INCIDENCE OF ADVERSE DRUG EVENTS AND POTENTIAL ADVERSE DRUG EVENTS - IMPLICATIONS FOR PREVENTION [J].

BATES, DW ;

CULLEN, DJ ;

LAIRD, N ;

PETERSEN, LA ;

SMALL, SD ;

SERVI, D ;

LAFFEL, G ;

SWEITZER, BJ ;

SHEA, BF ;

HALLISEY, R ;

VANDERVLIET, M ;

NEMESKAL, R ;

LEAPE, LL .

JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 1995, 274 (01) :29-34

[5] INCIDENCE OF ADVERSE EVENTS AND NEGLIGENCE IN HOSPITALIZED-PATIENTS - RESULTS OF THE HARVARD MEDICAL-PRACTICE STUDY-I [J].

BRENNAN, TA ;

LEAPE, LL ;

LAIRD, NM ;

HEBERT, L ;

LOCALIO, AR ;

LAWTHERS, AG ;

NEWHOUSE, JP ;

WEILER, PC ;

HIATT, HH .

NEW ENGLAND JOURNAL OF MEDICINE, 1991, 324 (06) :370-376

[6] Evaluating dispensing error detection rates in a hospital pharmacy [J].

Facchinetti, NJ ;

Campbell, GM ;

Jones, DP .

MEDICAL CARE, 1999, 37 (01) :39-43

[7] Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities [J].

Flynn, EA ;

Barker, KN ;

Pepper, GA ;

Bates, DW ;

Mikeal, RL .

AMERICAN JOURNAL OF HEALTH-SYSTEM PHARMACY, 2002, 59 (05) :436-446

[8]

Food and Drug Administration, 2004, FDA ISS BAR COD REG

[9] Drug complications in outpatients [J].

Gandhi, TK ;

Burstin, HR ;

Cook, EF ;

Puopolo, AL ;

Haas, JS ;

Brennan, TA ;

Bates, DW .

JOURNAL OF GENERAL INTERNAL MEDICINE, 2000, 15 (03) :149-154

[10] Adverse drug events in ambulatory care [J].

Gandhi, TK ;

Weingart, SN ;

Borus, J ;

Seger, AC ;

Peterson, J ;

Burdick, E ;

Seger, DL ;

Shu, K ;

Federico, F ;

Leape, LL ;

Bates, DW .

NEW ENGLAND JOURNAL OF MEDICINE, 2003, 348 (16) :1556-1564

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