保険調剤薬局における薬剤のリスクマネジメント (II)

―調剤エラーによる危険性の検討―

抄録

At the Niigata Pharmacy, there were 1,244 dispensing errors, consisting of 1,236 internal errors, 8 external errors and no accidents, during the year from April 2002 to March 2003. Eight-hundred-and-forty-one of the dispensing errors were safety-related, equivalent to 67.6% of all dispensing errors, and 1.6% of all prescriptions. Among the safety-related dispensing errors, 185 were adverse effect-related (14.9% of all dispensing errors) and 656 were symptom aggravation-related (52.7% of all dispensing errors). The breakdown for the safety-related errors was : about 40% for calculation errors, about 20% for dispensing omissions, about 15% for drug content errors, about 15% for dispensing other drugs in error and about 10% for other errors. The adverse effect-related errors consisted mainly of pharmaceutical mistakes, which were drug content errors, dispensing other drugs in error and dosage errors. On the other hand, symptom aggravation-related errors were mainly simple mistakes such as calculation errors and dispensing omissions. More than 90% of safety-related errors were calculation mistakes, with more than 74.6% of them being discovered at the halfway inspection and 24.5% being discovered at the final inspection.
Our findings seem to indicate that pharmacists can cause a lot of risk for patients so we must make all possible efforts to reduce our mistakes and establish a double or triple check system to prevent dispensing errors.