How Many Hospital Pharmacy Medication Dispensing Errors Go Undetected?

被引：71

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

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[No title captured]

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