注射剤によるリスクを回避するための薬剤師業務の構築 : 注射剤調剤から患者投与まで

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Many medical accidents concerning errors in the administration of injections have been reported in recent years but many of them could be prevented through the active involvement of pharmacists in this respect. At the Department of Pharmacy of the Municipal Ikeda Hospital, a ward pharmacy was established in April 2000 and the dispensing of injections, including the mixing of injections, was commenced. In October, 2001, an injection distribution surveillance system was also established. Under the system, injections are distributed to the patients' bedsides, information provided on the drugs in them and monitoring performed. We conducted a survey of the dispensing of injections and the surveillance system. The mixed injection preparations targeted by the survey were drip infusions for administration between 10 : 00 and 22 : 00 whose prescriptions were received by the Department of Pharmacy by 17 : 00 on the day before use, and injection preparations were mixed 4 times a day. The dispensing of injections was divided into 5 tasks : receipt of dispensing requests, preparation of labels, measuring of quantities, mixing of preparations, and preparation of infusion sets and each task was investigated for dispensing errors. Warnings were issued under the distribution surveillance system when pharmacists misidentified patients in distributing injections to the patient's bedside and the situation was investigated. The rate of pharmacist errors in mixing injection preparations was 2.23% in a 4-month period and though 0.04% of the preparations in error were sent to wards, they were not administered to patients. Out of the 7, 690 instances in which injections were distributed to the patient's bedside by pharmacists in the 4-month period, in 3 instances (0.04%) pharmacists were warned about misidentifying patients. All of errors were human errors, but did not lead to errors in administration. This study suggests that risk of errors made with injections could be avoided by the close involvement of pharmacists in the work of administering injections. Greater use of codes was suggested for preventing human errors in future, since codes were printed on the injection in only 14.5% of the injections distributed during our survey. Besides the increased use of such codes, the development of an injection dispensing surveillance system using them is also necessary.
日本医療薬学会の論文
2005-02-10

注射剤によるリスクを回避するための薬剤師業務の構築 : 注射剤調剤から患者投与まで

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