我院改进形似医院制剂包装的探索与实践

Exploration and Practice of the Improvement of Look-alike Hospital Preparations Package in Our Hospital

目的:探索我院改进形似医院制剂包装的实践措施,以减少制剂混淆引发的发药差错,提高患者用药安全。方法:分析我院2006-2010年5年内门/急诊药房的处方中由包装形似引发的发药差错,通过将外用与内服液体医院制剂的包装瓶瓶盖与各自标签的颜色统一,实施包装改进。结果与结论:5年内由于包装形似引发的发药差错占发药差错总数的比例约为37.68%,其中医院制剂包装形似引发的占发药差错总数的比例约为6.02%;改进包装至今,我院尚未发生因医院制剂包装形似引起的发药差错。表明用改进包装设计来减少发药差错的措施是切实可行的安全措施,将为其他医疗机构制剂室提供借鉴,同时也可促进药品生产企业对形似药品的包装改进。

OBJECTIVE： To explore some exercisable measures of improving look-alike hospital preparations package in our hospital in order to reduce dispensing errors caused by look-alike preparations and improve patient medication safety. METHODS： The dispensing errors caused by look-alike preparations in outpatient department of our hospital during 2006- 2010 were analyzed. The package of hospital preparations was improved by unifying cap and label color of liquid for external and internal use. RE- SULTS ＆ CONCLUSIONS： In recent 5 years, dispensing errors caused by look-alike preparations accounted for 37.68% of total dispensing errors, among which look-alike hospital preparations accounted for 6.02% of total dispensing errors. The dispensing er- rors had not yet occurred due to look-alike hospital preparations since package had been improved. It is feasible safety measures and a reference for other hospitals to reduce dispensing errors by improving package design. It also will promote the packaging improve- ments for look-alike medications in the pharmaceutical industry.