TITLE:
Study of Factors Affecting Medical Incident: 2 Powdered Medication Dispensing
AUTHORS:
Yuka Miyachi, Chika Nakayama, Satomi Funahashi, Hiroyuki Shimada, Masayuki Takeuchi, Masafumi Ohnishi, Hiroko Saito, Taeyuki Oshima
KEYWORDS:
Dispensing Error, Eye Tracking, Pharmacist, Powdered Medication
JOURNAL NAME:
Pharmacology & Pharmacy,
Vol.10 No.6,
June
26,
2019
ABSTRACT: 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 the weighing process, without the
inspection of the prescription or checking weighed amount. Irregular doses for
infants and older patients require fine adjustments; therefore, the powders
dispensing checking system may not find all dispensing errors. It is important
for a pharmacist to, first, be written calculated weight on the prescription
and checked by themselves, and next to begin dispensation work. In the future,
as well as the powdered medication dispensing, it is necessary to make use of
measures for preventing errors in the various dispensing process, such as the
medication inspection, sterile products preparation, clinical practice et al.