소아처방 조제에서 나타난 조제과오의 유형 및 관련인자 고찰

Abstract

Dispensing errors can delay medical treatment and threaten patient`s life. Especially, pediatric prescriptions need the more skillful dispensing knowledge and technique about dosage and formulation than adult. Moreover the incidence of dispensing error in pediatric prescriptions is higher than adult. Dispensing errors were recorded and analyzed in order to find out mistake types and related factors. Changes after education were also analyzed. Also we considered a counterplan to prevent dispensing errors. Dispensing error reports were obtained from April to September in 2004 and arranged monthly. In this period, 257,451 cases of inpatient's and outpatient's prescriptions were dispensed by thirteen pharmacists in Seoul National University Children's Hospital pharmacy. The total incidence of dispensing error was 0.11% during six month and the monthly incidence was 0.10% on April, 0.20% on May, 0.14% on June, 0.07% on July, 0.05% on August and 0.09% on September. This decrease was due to the repeat education of attentions in dispensing. The incidence of dispensing errors related with counting mistakes was 38%, 29% in relation with incorrect dosage, 27% in relation with administration of different medicines, and 3% in relation with different dosage form. Dispensing position which has the highest error was powder position followed tablet or capsule, and injection site. The mean incidence numbers of dispensing errors were 5.2 cases a month in 10 experienced pharmacists who worked more than one year at the hospital pharmacy, 7.4 in 3 pharmacists who worked less than one year at the hospital pharmacy and the ratio was 1.4:1(in a beginning pharmacist : in a experienced pharmacist). And the mean incidence numbers of dispensing errors were 3.5 cases a month in 8 experienced pharmacists who worked more than one year at the children's hospital pharmacy, 6.9 in 5 beginning pharmacists who worked less than one year at the children's hospital pharmacy and the ratio was 2:1. According to this data, we could comprehend that the experience in the pediatric pharmacy was more influential in dispensing error than the experience at the hospital pharmacy itself. We concluded that the factors of dispensing error incidence in pediatric prescription depend on the review of dispensing error cases, an experience in the pediatric pharmacy, and a charge quantity of dispensing work. Therefore, to diminish the incidence of dispensing errors we need to intensify a review of dispensing error cases, to revise the dispensing system, and to carry out double checking prescriptions and weight checking for the powder.