title: [Establishment and evaluation of a system for preventing mis-administration of powder using bar codes printed on drug envelopes].
abstract: Even if drugs are accurately dispensed, it is difficult to ensure their safety in the absence of an error-free medication system when or after drugs are given to patients. In particular, most powders are white and are impossible to distinguish based on appearance after they are placed in powder packages. In this study, we newly developed a system in which prescription order information is bar-coded on drug envelopes, and read when powder is folded, facilitating efficient and accurate printing of the patient's name and drug name on powder packages. Seventy-one (86%) of 83 nurses surveyed indicated that the system was useful for resolving high-risk problems they had experienced: "when powder was taken from the envelope, the contents were unknown", and "the powder was administered to another patient."
authors.affiliation: Department of Pharmacy, Yamaguchi University Hospital, 1-1-1 Minamikogushi, Ube 755-8505, Japan.
authors.forename: Keizo
authors.initials: K
authors.lastname: Ishimoto
authors.forename: Miwako
authors.initials: M
authors.lastname: Ishihara
authors.forename: Noriko
authors.initials: N
authors.lastname: Okada
authors.forename: Tatsuko
authors.initials: T
authors.lastname: Adachi
authors.forename: Akira
authors.initials: A
authors.lastname: Kamiya
mesh_terms: D004348:Drug Labeling; D004349:Drug Packaging; D011307:Drug Prescriptions; D001330:Electronic Data Processing; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D008510:Medication Systems, Hospital; D004364:Pharmaceutical Preparations; D010607:Pharmacy Service, Hospital; D011208:Powders; D011795:Surveys and Questionnaires
chemical_list: D004364:Pharmaceutical Preparations; D011208:Powders