| บทคัดย่อ(English) |
Medication error is the leading problem in drug use processand reflect inadequate quanlity assurance of the system. Unitdose system has been designed and accepted as the most effectivemethod to overcome this defect. The objectives of this study were to determine the patternsand causes of the medication errors in 8 different wards usingtraditional (4 wards) and unit dose (4 wards) drug distributionsystems at Srisaket Hospital between June to December 1993. Three steps in drug process (prescribing,dispensing andadministering) was evaluated.Data in the first step was collectedthrough the routine dispensing process inspection of allprescription for 1 month and 176 of 6,452 items (2.7 %) werefound to be prescribing errors. However,these were judged asnon-serious errors. Frequency Of dispensing errors were comparable intraditional(48/ 1922;2.5%) and unit dose system (295/9977;2.95%). In traditional system, other error(19/0.99%),omission(13/0.68%) and wrong dose(S/0.42%) were leading types of errors.In unitdose system,other error (66/0.77 %),wrong dose (65/0.65%) andunordered drug error(64/0.64%) were top three types of errors.All errors found in this step were automatically corrected at thepharmacy. Three major causes of dispensing error were personnelerror,inappropriated system and excessive workload. Assessment of drug administration error revealed 437 (11.78%) and 629 (16.74 %) in traditional and unit dose systemsrespectively. Three major causes of administration error werepersonnel error,lack of knowledge and drug preparation error.Errors in wrong dose (234/6.31 %),omission (123/3.31 %) andunordered (46/1.24%) were most commonly found in the traditionalsystem. Wrong time (415/11.05 %),omission (91/2.42 %) and wrongdose error (46/1.22%) were commonly found in order of frequencyin unit dose system. Three major causes of the error wereinappropriated system,personnel error and error in Kardexpreparation. Although unit dose system in this study was found not to beeffective as expected when only frequency of errors wereconsidered. However,when wrong time error which is not a seriousproblem as compared to others was excluded. Unit dose systemremained superior to the conventional one.Further modification inunit dose system has to be done to improve its efficiency. |
