電子カルテシステムの注射認証データを利用した注射インシデント分析

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  • 秋場 道代
    Yamagata City Hospital Saiseikan, Committee of electronic health record
  • 岩渕 勝好
    Yamagata City Hospital Saiseikan, Committee of electronic health record
  • 片桐 茂
    Yamagata City Hospital Saiseikan, Committee of electronic health record
  • 平川 秀紀
    Yamagata City Hospital Saiseikan, Committee of electronic health record

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タイトル別名
  • Injection incident analysis using the injection enforcement certification data of the electronic health record system
  • デンシ カルテ システム ノ チュウシャ ニンショウ データ オ リヨウシタ チュウシャ インシデント ブンセキ

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In January 2006 an electronic health record system was introduced at the Yamagata City Hospital Saiseikan. Simultaneously the automatic ampoule picking system and the bar-code injection enforcement certification system were adopted with the purpose of preventing patients' misunderstanding and errors in injection enforcement.<BR>We analyzed the incident reports on injection enforcement during the eight months just after the system's introduction, comparing them with 197, 121 cases of all injection enforcement certification data over this same period.<BR>The incident rate in the period was 0.049% totally. According to the incident level of our hospital, level 0 was 0.009%, level 1 0.033%, level 2 0.007% and there were no accidents of more than level 3, which are harmful to patients.<BR>During one day, high incident rates were observed at 7:00, 12:00, 17:00 and 22:00, but this did not coincide with the number of injection enforcement.<BR>In a classification of drug efficacy, the incident rate with antineoplastic drug was the highest at 0.668%, and the next highest was with hormonal drugs at 0.093%.<BR>The incident rate increased with the number of mixed drugs. Especially, in the cases of mixing more than 3 drugs, the incident rate was significantly higher than mixing no or with less drugs.<BR>There was no difference though in the incident rate between usual orders and temporary orders.

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