[The approaches to factors which cause medication error--from the analyses of many near-miss cases related to intravenous medication which nurses experienced].
Given the complexity of the intravenous medication process, systematic thinking is essential to reduce medication errors. Two thousand eight hundred cases of 'Hiyari-Hatto' were analyzed. Eight important factors which cause intravenous medication error were clarified as a result. In the following I summarize the systematic approach for each factor. 1. Failed communication of information: illegible handwritten orders, and inaccurate verbal orders and copying cause medication error. Rules must be established to prevent miscommunication. 2. Error-prone design of the hardware: Look-alike packaging and labeling of drugs and the poor design of infusion pumps cause errors. The human-hardware interface should be improved by error-resistant design by manufacturers. 3. Patient names similar to simultaneously operating surgical procedures and interventions: This factor causes patient misidentification. Automated identification devices should be introduced into health care settings. 4. Interruption in the middle of tasks: The efficient assignment of medical work and business work should be made. 5. Inaccurate mixing procedure and insufficient mixing space: Mixing procedures must be standardized and the layout of the working space must be examined. 6. Time pressure: Mismatch between workload and manpower should be improved by reconsidering the work to be done. 7. Lack of information about high alert medications: The pharmacist should play a greater role in the medication process overall. 8. Poor knowledge and skill of recent graduates: Training methods and tools to prevent medication errors must be developed.
Kyorin University, School of Health Sciences.
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Kawamura
D003142:Communication; D007275:Injections, Intravenous / Q000295:instrumentation / Q000592:standards*; D008508:Medication Errors / Q000517:prevention & control*; D009729:Nursing / Q000592:standards*; D009817:Office Management; D010355:Patient Identification Systems / Q000379:methods; D010818:Practice Patterns, Physicians'; D011356:Product Labeling / Q000592:standards