Medication Error in Inpatient Department at Bumrasnaradura Institute - ความคลาดเคลื่อนทางยาในงานบริการจ่ายยาผู้ป่วยใน สถาบันบำราศนราดูร

Abstract

          The purpose of this study was to analyze medication error and management of conventional drug distributing service in inpatient department at Bamrasnaradura Institute. During October 2004-March 2005, a survey was conducted to collect retrospectively rate of medication errors. Data collected were analyzed, together with documentation and observation, in order to develop work instruction. Brainstorming sessions of practitioners were carried out to identify causes of medication errors, to process medication error management, and to improve quality of work process.

           Results showed there were prescription error 0.089 percent, transcribing error 0.324 percent, pre-dispensing error 1.569 percent, dispensing error 0.121 percent and administration error 0.080 percent. Medication errors could happen at any work instruction and could directly and indirectly affect patients. Causes of medication errors were classified into 4 groups: 1) deficiency of standard work procedure, 2) overlap and complication of work system, 3) practitioners lack of information and knowledge and 4) negligence. Recommendations for medication error management focused on rejection of work inefficiency and establishment of efficient work process including work outcome audits. Establishment system of double checks every work process. Improvement of follow up system, recording system and analysis system of medication error to improve drug distributor safety service and prevent repetition of medication errors.

            Medication error management plays an important role in improving quality of services continuously as part of basic fundamental of hospital accreditation.