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OBJECTIVE To reduce dispensing errors in pharmacy intravenous admixture service （PIVAS） of children’s hospitals. METHODS The risk of dispensing procedures in our PIVAS was identified by applying failure mode and effect analysis （FMEA） model. Potential failure modes that might lead to dispensing errors in each link were determined， and failure causes were analyzed. The severity， incidence and detection degree of potential failure modes were quantitatively scored， and their risk priority number （RPN） was calculated to screen failure modes that needed to be improved in priority； the corresponding improvement measures were developed by 6S management method from six aspects， namely， finishing （seiri）， rectifying （seiton）， sweeping （seiso）， sanitation （seiketsu）， literacy （shitsuke） and safety. The effect of intervention before and after rectification was evaluated. RESULTS Based on the RPN， 32 potential failure modes were selected， of which a total of 18 critical failure modes that needed to be improved in priority. After implementing corresponding measures according to 6S management method， the RPN of 18 critical failure modes decreased. The total RPN decreased from 497 to 142 with a decrease rate of 71.43%. The error rates of 15 critical failure modes were significantly lower than before implementation （P＜0.05）. CONCLUSIONS Applying FMEA model and 6S management method to the risk control of all aspects of PIVAS workflow can effectively reduce the risk of PIVAS dispensing errors and ensure the safety of children’s intravenous medication.
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Background: Poor physician handwriting may lead to wrong comprehension and dispensing errors. This study was planned to objectively assess the quality of handwriting of doctors and their readability by physician, pharmacist and patient and to explore the impact of experience and familiarity of pharmacist on prescription readability.Methods: A 100 prescriptions were selected and were given to a pharmacist, a doctor and an educated lay person. They rated the readability of prescriptions on a scale of 1-10 and an average readability score was calculated. Prescriptions with average score 4 or less were subjected to analysis by a pharmacist working at the hospital dispensary (P1) and another pharmacist not working at hospital pharmacy (P2).Results: Average score of pharmacist, physician and lay person was 6.14, 5.2 and 3.14 respectively. A total of 28 prescriptions, containing 93 medicines, had an average readability score of 4 or less. P1 was not able to comprehend one medicine while P2 could not comprehend 19 medicines out of these 93. The performance of both pharmacists was compared by diagnostic tests (EPI 6.04D). The sensitivity of P2 was 80% (95% CI 70.6-87.7), specificity and positive predictive value were 100, and negative predictive value was 5.3 (0.3-28.1).Conclusions: Familiarity of the pharmacist with the prescribing physicians’ handwriting is an important factor in comprehension of poorly legible prescriptions. This could limit the patients to pharmacists around the prescribers. Implementation of appropriate steps need to be assured to minimize the prescription errors.
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OBJECTIVE:To strengthen the comprehensive control of drug dispensing errors in our hospitals and ensure the medication safety of patients. METHODS:The steps and related contents for drug dispensing errors implemented in our hospital based on hazard analysis and critical control point method(HACCP)were introduced,and the management effects were evaluated by comparing the dispensing error before(2015)and after management(2016). RESULTS:Starting from establishing groups,our hospital drew flow chart of drug dispensing,and plans [including hazard analysis,determining critical control points(CCP),estab-lishing critical limits (CL),monitoring system,correlative measures,confirming process and quality records] were developed based on HACCP principle. And 4 CCPs were identified,naming reviewing prescription,dispensing drugs,writing drug bags or pasting labels and delivering the drugs to patients. Related measures were implemented,which had achieved the effective manage-ment and control for drug dispensing. Compared with before implementing HACCP,the drug dispensing error rate in our hospital was declined by 84.73%(0.753‰ vs. 0.115‰). CONCLUSIONS:Scientifically applying HACCP for drug dispensing in hospital can effectively control the drug error risk and promote the medication safety of patients.
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OBJECTIVE:To reduce dispensing errors in Pharmacy intravenous admixture service(PIVAS),improve compound-ing quality of transfusion and guarantee the safety and rationality of clinic transfusion. METHODS:The case tracking method was applied to analyze each link of the work in PIVAS to find the reasons of configuration errors and control risk;and then the system tracking method was applied to analyze the hidden safety risk and the crack of quality from the inside of the system and work flow. Countermeasures and supporting continuous improvement were established to evaluate the effect of management before and after 6 months. RESULTS:Tracer methodology(TM)was adopted to find out the weakness in the key link and work flow of the cause of the configuration errors,the relative work pattern and work environment was improved,the relative system was formulated and completed,strength of rewards and punishment was increased. Through the implementation of the countermeasures,the number of dispensing errors was reduced from 81 to 38,and the error rate was reduced from 0.035% to 0.011%(P<0.01). CONCLU-SIONS:TM can be adopted in the key link and work flow of the cause of the configuration errors,aim at formulate and strictly carry out relative countermeasures to reduce errors in PIVAS,and promote the safety of drug use.
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OBJECTIVE:To establish a new semi-automatic drug dispensing mode,with proper cost,which falls in between full-automatic drug dispensing mode and manual drug dispensing mode,good work efficiency,standard and simple operation meth-od and meets national laws and regulations. METHODS:A semi-automatic drug dispensing system was designed,in which the in-formation in the drug dispensing sheet could be automatically printed on the drug bag,and automatic bagging,packaging and deliv-ery of drugs were realized. Such drug dispensing system included hardware(mechanical structures such as drug turntable and drug funnel,transmission device,etc.)and software control systems(the program of interface with hospital information system,micro control unit software,computer software,etc.). Through commissioning,formal operation and statistics,based on 18 oral drug dis-pensing sheets with the same contents,calculated the time of drug dispensing and the number of drug dispensing errors by 3 phar-macists respectively in manual drug bag dispensing mode and semi-automatic drug dispensing mode,to evaluate the effect of the semi-automatic drug dispensing system. RESULTS:From commissioning in May 2012 to formal operation in September 2012,the system operated normally and utility model patents were obtained. In the two modes,the total time of drug dispensing was 481 and 397 min (t=6.82,P<0.001),the numbers of drug dispensing errors were 25 and 7 (χ2=9.353 8,P=0.002 2),respectively. There was statistical significance. CONCLUSIONS:The semi-automatic drug dispensing system has higher efficiency and less num-ber of drug dispensing errors compared with manual drug bag dispensing mode and lower cost compared to full-automatic drug dis-pensing system. It deserves promotion.
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<b>Objective: </b>This study quantitatively analyzes the factors causing dispensing errors in community pharmacies and explores the characteristics of these factors and their order of importance.<br><b>Design and Methods: </b>We collected data records on the contents and causes of dispensing errors as reported between April and July 2009 by a total of 320 pharmacists at 56 stores of two pharmacy chains (15 stores in Hokkaido and 41 stores in the Kansai area). We focused on the following three types of dispensing error: 1) “measurement error”, 2) “wrong drug dispensing error” and 3) “wrong dosage form specification error”. We conducted multiple regression analyses and discriminant analyses with occurrence frequency of each type of error as dependent variables and count frequency of each causal factor as independent variables.<br><b>Results: </b>The result of the multiple regression analyses indicated that the primary causes of the three types of errors in order of strength of the regression coefficients were as follows. For “measurement error”: 1) pharmacist’s wrong assumption and 2) calculation error; for “wrong dosage form specification error”: 1) insufficient confirmation of prescription and 2) pharmacist’s wrong assumption; for “wrong drug dispensing error”: 1) pharmacist’s wrong assumption and 2) insufficient confirmation of prescription. The results of the discriminant analysis indicated that only for the discriminant coefficient between “wrong dosage form specification error” and “wrong drug dispensing error” no significant difference in the mean was found (<i>p</i>=0.539).<br><b>Conclusions: </b>Results show that partly different factors cause “measurement error” as compared with the two other types of dispensing errors. In addition, while basically the same factors were found to cause “wrong drug dispensing error” and “wrong dosage form specification error,” there was a difference in the order of importance of these factors. This study uncovered differences in terms of causal factors affecting each dispensing error type.
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Spectacles are routinely prescribed by the ophthalmologist and dispensed by the opticians. We investigated how frequently the spectacles are not dispensed as prescribed and whether the frequency of inaccurate spectacles would decrease if the patients, at the time of collecting spectacles, ask the optician to verify that the spectacles have been dispensed accurately. We found inaccurate spectacles in about one-third of our patients and incorrect spherocylinders more frequently with an error in the spherical element and cylinder axis. These inaccuracies decreased significantly when patients while collecting spectacles, asked the optician to verify the accuracy of the spectacles dispensed. It is suggested that while prescribing spectacles, the patients should be made aware of the possibility of dispensing errors. To decrease the frequency of incorrect spectacles, the patients while collecting spectacles, should ask the optician to check whether the spectacles have been dispensed accurately.
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Recently, the number of physicians using Kampo (Japanese traditional herbal) medicines has been increasing in Japan, and it is becoming more common for pharmacists to dispense Kampo medicines. As Kampo medicines become more popular, in addition to extract formulae, the use of decocting formulae that are more suited to each patient's predisposition and symptoms has increased. Therefore, more pharmacists are dispensing such decocting formulae. However, dispensing decocting formulae can be a complicated task. The risk of dispensing errors is not small. In present paper, we examined preventive measures based on investigations of errors involving decocting formulae in our Kampo clinic. From 1990 to 1999, there were 54 cases in which errors were found after patients received their medicines, and 44 of these cases were dispensing errors. To prevent such errors, in addition to having the knowledge of Kampo medicine and medicinal herbs that is needed for dispensing decocting formulae, it is also necessary to understand the contents of the prescription. The most important preventive measures are to re-inspect the weight and contents of the prescription after preparing it, and to do a final inspection of the medicine contents with the patient. It is expected that this report will play a role in preventing dispensing errors of Kampo medicines by pharmacists.