Our hospital developed a dispensary inspection system for injections in October, 2001 as a preventive measure against the administration of wrong instillations due to a misidentification of patients and started a service for delivering the injections prepared at the pharmacy to the patients' bedside. The injections delivered by pharmacists are those for instillation prepared at the pharmacy to be administered between 10 : 00 and 22 : 00. The injection delivery service was monitored by the dispensary inspection system using two-dimensional codes (QR codes) printed on the labels of instillation bottles at 3 points, i.e. at dispensing, at delivery, and at administration. The number of cases in which pharmacists were warned by the injection dispensary inspection system and the circumstances of warning were investigated during the 4 months from February 1 to May 31, 2002. During the 4 months, 3 (0.04%) of the 7, 690 deliveries of injections by pharmacists to the patients' bedside were misidentified. All misidentifications were caused by human error. The close involvement of pharmacists in the delivery of injections has contributed to the prevention of accidents due to the erroneous delivery of injections.
