항암제 주사 조제 오류의 발생률, 유형 및 원인분석
Incidence, types and causes of preparation errors in intravenous chemotherapeutic agent
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The objective of this study is to investigate the incidence, types, stages and causes of preparation errors in intravenous chemotherapeutic agents in order to prevent medication error and improve patient safety. The study was performed in the Outpatient Department of Pharmacy in ASAN Medical Center during a nine month period from January to September 2011. Preparation errors were both selfreported and non-self-reported. Analysis included 99,085 preparations, and preparation errors were detected in 155 preparations (0.16%, 95% CI=0.10%-0.21%). Common types of errors were incorrect dosage of drugs (18%), incorrect volumes of diluents (14%), and spills in the process of preparation (13%). The most common stages of error occurrence were the preparing stage (51%) and checking stage before preparation (17%). Causes included mistakes in device operation (16%), process violation (16%), and incorrect identification of drugs or diluents (13%). Other causes included poor quality of medication (26%), unusual processes of preparation (15%), and insufficient support of computerized systems (27%). To prevent error, working routines should be established for the through verification of the systems, and to analyze, change, and monitor the processes and environments.
Abstract
The objective of this study is to investigate the incidence, types, stages and causes of preparation errors in intravenous chemotherapeutic agents in order to prevent medication error and improve patient safety. The study was performed in the Outpatient Department of Pharmacy in ASAN Medical Center during a nine month period from January to September 2011. Preparation errors were both selfreported and non-self-reported. Analysis included 99,085 preparations, and preparation errors were detected in 155 preparations (0.16%, 95% CI=0.10%-0.21%). Common types of errors were incorrect dosage of drugs (18%), incorrect volumes of diluents (14%), and spills in the process of preparation (13%). The most common stages of error occurrence were the preparing stage (51%) and checking stage before preparation (17%). Causes included mistakes in device operation (16%), process violation (16%), and incorrect identification of drugs or diluents (13%). Other causes included poor quality of medication (26%), unusual processes of preparation (15%), and insufficient support of computerized systems (27%). To prevent error, working routines should be established for the through verification of the systems, and to analyze, change, and monitor the processes and environments.
참고문헌 (12)
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