A comparison of medication errors before and after implementation of a unit dose drug distribution system in a medicine ward (การเปรียบเทียบความคลาดเคลื่อนในการใช้ยาที่หอผู้ป่วยอายุรกรรม ก่อนและหลังการใช้ระบบการกระจายยาแบบยูนิตโดส)


  • สาลินี คูหะโรจนานนท์ Faculty of Pharmaceutical Sciences Khon Kaen University
  • ดร.อรุณศรี ปรีเปรม Faculty of Pharmaceutical Sciences Khon Kaen University
  • อาภรณี ไชยาคำ Faculty of Pharmaceutical Sciences Khon Kaen University
  • เชิดชัย สุนทรภาส Faculty of Pharmaceutical Sciences Khon Kaen University


Medication errors at a genera l hospital medical-ward , the drug distribu tion of which was being changed from the long-used traditional to unit dose drug distribution. The overall medication errors including classification of errors (omission, unauthorized drug, wrong dose, wrong dosage form and wrong tim e), and the causes were estimated . The investigation was performed at a fixed duration u sing the disguised­ observation technique by the same pharmaci st investigator. The number of samples of all oral dosage administration to the i n-patie nts at scheduled times were 1,600 for each drug distribution sy stem and the statistical comparison of data was by Chi-square t est. The overall medication errors reduced significantly (p<0.05) from 16.8 to 3.296 after the implementation of the unit dose system . The result wa s in accordance to the other two nati onal studies and four other international studi es. Omission, unauthori zed drug, wrong dose and wrong time errors reduced significantly from 7.3%, 1.596 , 6.1%, 1.8%, t o 1.8%, 0.3%, 0.4 %, 0.8%, respectivel y (p<0.05). The error due to wrong dosage from administration was reduced from 0.3% to 0.0% (p=0.5).The causes of medicati on errors found in traditional drug distribution system were error in medication card, human error, over workload of nurse, poor floor stock sy sem. Hum an error and the lack of double checking system was found in unit dose drug distribu1ion system. In conclu sion, the implementation of the un it dose distribution system at a gen eral hospital could reduce both medi cation errors and workl oad of nurses. The result s m ay be applied in improving the 2 drug distribution systems in other regional medical center hospital s.


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