항암화학요법의 처방 검토 시 약사가 중재한 처방 오류 내용 분석
Optimizing physician's prescription through pharmacist’s intervention in cancer chemotherapy
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Abstract
Medication error is defined as“ any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the heath care providers”. Prescribing error is the most avoidable event among them and preventing the error could decrease the development of a lot of medication error. The objectives of this study are to understand causal factors related to prescribing errors and to find the resolutions for reducing prescribing errors. The role of pharmacist in preventing medication error is also assessed. Oncology pharmacists had recorded all prescribing errors identified in chemotherapy medication orders from September 2006 to June 2007. During the data collecting period, 24,482 medication orders were examined and 924 of them had prescribing errors(3.77%). According to the order type, there were more prescribing errors in irregular orders(57.03%) than regular orders(38.96%). So much more attention and caution are needed when the doctors prescribe the chemotherapy orders and when the pharmacists verify the orders. When analyzing the order based on the cause of the prescribing error, the lack of the information about the order(44.37%) and error occurred by input mistake(36.69%). Therefore the education for the prescribers about the drug information must be carried out. The most frequent prescribing error type was the dosing error(29.65%) followed by the strength error(25.43%), the dilution error(15.91%), the number error(8.23%), and the omission error(3.79%). By using the chemotherapy ordering system, these types of error could be avoidable but the prescribers don't know about it and how to use it. So it is needed to encourage prescribers to use the chemotherapy ordering system. Most of all, the communication and mutual collaboration between doctors and pharmacists are essential to reduce prescribing errors and it is needed to educate prescribers in some areas. And our finding suggests that other hospital pharmacist should analyze the types of chemotherapy prescribing error to find out the way to decrease the incidence of making prescribing errors and to administer chemotherapeutic drugs safely to cancer patients.
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