ケア移行で薬局薬剤師により回避されたメディケーションエラーの特徴

抄録

This study aimed to clarify the characteristics of medication errors (MEs) prevented by community pharmacists in patients transitioning from hospital to home or in-facility care.

We analyzed ME cases collected by the Japan Council for Quality Health Care in the Project to Collect and Analyze Pharmaceutical Near-Miss Events between January and December 2024. Patients were classified into the transition and non-transition of care groups. Patient backgrounds, details of MEs, and sources of information identified as ME by pharmacists were compared between the two groups.

The transition of care group included 1,835 cases, whereas the non-transition of care group included 89,693 cases. Patient background characteristics significantly associated with the transition of care include age ≥ 60 years. Among causative medications, significant associations were observed for antihypertensive drugs, peptic ulcer drugs, antidiabetic drug, and anticoagulants.

Dosage, duplication of the same component, and omission of prescriptions were significantly associated with the transition of the care group. The sources of information identified as ME by pharmacists were prescription records and information sheets.

This study clarified the characteristics of MEs prevented by community pharmacists during the transition of care. Sharing patient information between hospital and community pharmacists should be enhanced, and pharmacists should confirm and evaluate pharmacotherapy before and after transition of care.