A qualitative study on medication errors in process for providing chemotherapy：An example of a medical center
Date Issued
2006
Date
2006
Author(s)
Su, Chiu-Feng
DOI
zh-TW
Abstract
If there is inappropriate prescription, dispensing mistake or administration error in chemotherapy process, for example inappropriate high dose chemotherapy agent, it may spoil therapeutic outcome and result in main organ failure even death. In the process of high- risk chemotherapy agent administration, error may happen in any medication-use process, including physician prescription and transcription, pharmacist dispensing, and nurse administration, fluid supplement.
The goal of this study is to find the experience and viewpoint the factors of medication errors in chemotherapy agent administration process. This is a qualitative study for personal interviews with relevant medical staff. The medical staffs include four physicians (two pediatric physicians, two hematologists), eight pharmacists, ten nurses (six in pediatric ward, two in hematology ward) and three patient families. We investigate safety protection mechanism and medication errors in medication-use process for chemotherapy.
The study findings are:
(1) Physician errors: pediatric physician has more personal errors including uncertain recheck; hematologist has more systemic errors including non-standardized protocol, unfamiliar resident prescription, and lack of standardized format, scratchy handwriting and oral prescription.
(2) Pharmacist errors: most of pharmacist errors are systemic errors, uncertain recheck is the most common error, other errors include too may handwriting procedures, heavy prescription loading and time strain.
(3) Nurse errors: in pediatric wad, personal error is main. Errors including uncertain medication and fluid recheck. In hematological ward, most errors belong to systemic factors, including unclear prescription writing, careless attitude, and failure of safety protection mechanism.
(4) The safeguards in various medication-use processes in system: recheck is necessary, standardized therapeutic protocol, simplified procedure, and reduction of transcription should be set up. Patient and family suggest medical staff should actively supply relevant medical information, and they themselves should learn knowledge voluntarily.
According to above findings, we have some suggestions:
(1) Our suggestion to hematologist is the order and prescription should be clear, and suggestion to pharmacy and nurse staff is to enforce the actual execution though recheck is certain.
(2) Our suggestion to pharmacy department is to reduce staff redeployment and handwriting work.
(3) Organization should set up and accumulate standardized chemotherapy protocol, and order standardized format Chemotherapy treatment ward should be assembled and integrated, and nurse staff training will be more concise and effective
(4) In order to give each department in treatment enough time, the rule of inward patient chemotherapy should be clearly and certainly executed.
(5) Our suggestion to future researcher is to enlarge the study targets to all medical centers and district hospitals, to combine qualitative and focus group interviews to cover both data depth and width.
Key words: chemotherapy agent, prescription error, dispensing error, administration error, safety protection
Subjects
化學治療藥物
處方錯誤
調配錯誤
给
藥錯誤
安全防護機制
chemotherapy agent
prescription error
dispensing error
administration error
safety protection
Type
thesis