Abstract

BackgroundThere are many reports regarding various medical institutions’ attempts at incident prevention, but the relationship between incident types and impact on patients in drug name errors has not been studied. Therefore, we analyzed the relationship between them, while also assessing the relationship between preparation and inspection errors. Furthermore, the present study aimed to clarify the incident types that lead to severe patient damage.MethodsThe investigation object in this study was restricted to “drug name errors”, preparation and inspection errors in them were classified into three categories (similarity of drug efficacy, similarity of drug name, similarity of drug appearance) or two groups (drug efficacy similarity (+) group, drug efficacy similarity (−) group). Then, the relationship between preparation and inspection errors was investigated in three categories, the relationship between incident types and impact on patients was examined in two groups.ResultsThe frequency of preparation errors was liable to be caused by the following order: similarity of drug efficacy > similarity of drug name > similarity of drug appearance. In contrast, the rate of inspection errors was liable to be caused by the following order: similarity of drug efficacy < similarity of drug name < similarity of drug appearance. In addition, the number of preparation errors in the drug efficacy similarity (−) group was fewer than that in the drug efficacy similarity (+) group. However, the rate of inspection errors in the drug efficacy similarity (−) group was significantly higher than that in the drug efficacy similarity (+) group. Furthermore, the occupancy rate of preparation errors, incidents more than Level 0, 1, and 2 in the drug efficacy similarity (−) group increased gradually according to the rise of patient damage.ConclusionsOur results suggest that preparation errors caused by the similarity of drug appearance and/or drug name are likely to lead to the incidents (inspection errors), and these incidents are likely to cause severe damage to patients subsequently.Electronic supplementary materialThe online version of this article (doi:10.1186/s40780-015-0011-x) contains supplementary material, which is available to authorized users.

Highlights

  • There are many reports regarding various medical institutions’ attempts at incident prevention, but the relationship between incident types and impact on patients in drug name errors has not been studied

  • The relationship between preparation and inspection errors was analyzed in three categories, the relationship between incident types and impact on patient was examined in two groups

  • By comparing the rates of inspection errors between error type (d) and (f ), between error type (e) and (f ) in the double similarity class, it was revealed comprehensively that the rate of inspection errors was liable to be caused by the following order: similarity of drug efficacy < similarity of drug name < similarity of drug appearance, while the frequency of preparation errors was liable to be a result of the reverse order

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Summary

Introduction

There are many reports regarding various medical institutions’ attempts at incident prevention, but the relationship between incident types and impact on patients in drug name errors has not been studied. Tsuji et al Journal of Pharmaceutical Health Care and Sciences (2015) 1:11 regarding the prevention of incidents in oral and external drugs in various medical institutions [1-5], and many analytical studies have been conducted regarding the probability of drug name confusion [6-11], but the relationship between incident types and impact on patients in drug name errors has not been studied. The relationship between preparation and inspection errors was analyzed in three categories, the relationship between incident types and impact on patient was examined in two groups

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