|
KMID : 0869620120290010073
|
|
Journal of Korean Society of Hospital Pharmacists
2012 Volume.29 No. 1 p.73 ~ p.80
|
|
|
Incidence, types and causes of preparation errors in intravenous chemotherapeutic agent
|
|
Heo Young-Seol
Kang Min-Kyung
Kim Hee-Se
Song Yung-Cheon
|
|
|
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.
|
|
|
KEYWORD
|
|
|
chemotherapeutic agent, medication error, preparation error
|
|
|
FullTexts / Linksout information
|
|
|
|
|
|
Listed journal information
|
|
|
|