Study of Factors Affecting Medical Incident: 2 Powdered Medication Dispensing

• 作者: Chika Nakayama Hiroko Saito Hiroyuki Shimada Masafumi Ohnishi Masayuki Takeuchi Satomi Funahashi Taeyuki Oshima Yuka Miyachi
• 来源期刊: 药理与制药(英文)
• 学科: 医学
• 关键词: DISPENSING ERROR Eye TRACKING PHARMACIST Powdered MEDICATION
• 年，卷（期）: 2019,（6）
• 页码范围: 309-317
• 页数: 9页
• 分类号: R73

摘要

Medical incidents have been collected, analyzed and built up preventive measures by each medical institution for a long time. For powdered medication, there is the problem that it is difficult to tell at a glance the quantity of the active ingredient in the medication that has been dispensed and the quantities that have been mixed together. Therefore, special prevention measures are considered essential. In this study, we examined the work content of pharmacists’ powdered medication dispensing, using an eye-tracking technology of measuring a human eye movement, and studied on factors that affect medical incident. Participants were five pharmacists with 8 to 26 years of working experience (expert), and five pharmacists with less than one year of working experience (newcomer). Gaze measurement experiments were implemented for powdered medication dispensing during regular work activity. The gaze measurement equipment used was Tobii Pro Glasses 2. Based on the results of the eye tracking, newcomer had a longer dispensing time than expert for all powdered medication dispensing. In particular, it was suggested that there is a close relationship to “years of experience” and “weighing and mixing skills.” Experts did unwasted and efficient movements, when preparing the dispensing apparatus, taking medications from the shelves, and scanning the barcode in the powders dispensing checking system. These movements led to shorter working time in experts. In contrast, newcomer had individual differences at the dispensing. Even with the same pharmacist, the work progression differed depending upon the prescription. Therefore, it is thought that the factor of common error was inadequate check and overlooked. The state that it’s messy on the workplace is also considered highly likely to cause dispensing mistakes. At the weighing, expert started weighing after the inspection of the prescription and checking weighed amount. However, certain newcomer dispensed to depend on the powders dispensing checking system only for th