Involvement of Pharmacists in Preventing Errors in the Administration of Injections

Accession number;05A0182837
Title;Involvement of Pharmacists in Preventing Errors in the Administration of Injections
Author; MYOTOKU MICHIAKI (Ikeda Municipal Hospital, JPN)
Journal Title;Japanese Journal of Pharmaceutical Health Care and Sciences
Journal Code:Y0888A
ISSN:1346-342X
VOL.31;NO.2;PAGE.89-98(2005)
Figure&Table&Reference;FIG.7, TBL.8, REF.19
Pub. Country;Japan
Language;Japanese
Abstract;Many medical accidents concerning errors in the administration of injections have been reported in recent years but many of them could be prevented through the active involvement of pharmacists in this respect. At the Department of Pharmacy of the Municipal Ikeda Hospital, a ward pharmacy was established in April 2000 and the dispensing of injections, including the mixing of injections, was commenced. In October, 2001, an injection distribution surveillance system was also estab-lished. Under the system, injections are distributed to the patients' bedsides, information provided on the drugs in them and monitoring performed. We conducted a survey of the dispensing of injections and the surveillance system. The mixed injection preparations targeted by the survey were drip infusions for administration between 10:00 and 22:00 whose prescriptions were received by the Department of Pharmacy by 17:00 on the day before use, and injection preparations were mixed 4 times a day. The dispensing of injections was divided into 5 tasks: receipt of dispensing requests, preparation of labels, measuring of quantities, mixing of preparations, and preparation of infusion sets and each task was investigated for dispensing errors. Warnings were issued under the distribution surveillance system when pharmacists misidentified patients in distributing injections to the patient's bedside and the situation was investigated. The rate of pharmacist errors in mixing injection preparations was 2.23% in a 4-month period and though 0.04% of the preparations in error were sent to wards, they were not administered to patients. Out of the 7,690 instances in which injections were distributed to the patient's bedside by pharmacists in the 4-month period, in 3 instances (0.04%) pharmacists were warned about misidentifying patients. All of errors were human errors, but did not lead to errors in administration.... (author abst.)