当院における注射剤調剤での過誤解析とその対策

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The system of intravenous injections (i.v.) being mixed by pharmacists is necessary to prevent contamination and dispensing errors. Such a system was started at the Municipal Ikeda Hospital on April 2000. The dispensing of injections consists of five steps, including the labeling, dispensing, setting and mixing, and the application of check systems. Dispensing errors that induced serious medical complications were examined over a 4 -month period (2000.10.1〜2001.1.31). In addition, resource management during dispensing errors were researched, and countermeasures against dispensing errors were developed. Dispensing errors involving i.v. mixing, which were identified after the preparation had been taken to the ward by nurses, were also surveyed for a 4-month period (2001.6.1.〜9.30). There were 9,611 i.v. mixing by pharmacists in a4-month period (2000.10.1〜2001.1 .31). There were 214 dispensing errors (2.23%) during those 4 months, those discovered in the final check comprised 0.28% (27cases), while those involving i.v. mixing taken to the ward by nurses was 0.04% (4 cases). The percentage of serious dispensing errors was 0.01% (1 case). Fortunately, these mixed i.v. preparations were not administered to patients. In the second survey, there were 10,478 i.v. mixings by pharmacists in a 4-month period (2001.6.1〜9.30). There was only 1 case (0.01%) of a dispensing error involving i.v. mixing identified after being taken to the ward by nurses. There were no cases involving serious dispensing errors. These erroneous instances of i.v. mixing were not administered to patients. When these two surveys are compared, no significant difference was observed, but the number of errors decreased after the establishment of countermeasures to reduce dispensing errors. As a result, it became clear that dispensing errors could occur at any step, but they were preventable by both making several checks and by developing countermeasures against dispensing errors at each step.
日本医療薬学会の論文
2002-08-10

当院における注射剤調剤での過誤解析とその対策

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