การพัฒนาระบบรายงานความคลาดเคลื่อนทางยาในโรงพยาบาลส่งเสริมสุขภาพตำบล (รพ.สต.) เครือข่ายบริการสุขภาพอำเภอเมืองจันทร์ จังหวัดศรีสะเกษ

Abstract

The objectives of this research were to: 1) develop the report system and increase the number of medication error reports in Muangchan Health Promoting Hospitals 2) evaluate and analyze the causes of medication error in Muangchan Health Promoting Hospitals. A quasi-experimental research method was applied in this study. The study was divided into 2 phases. In phase 1, 21 officers of Muangchan Health Promoting Hospitals were pre-tested and post-tested before add intervention. In phase 2, an online medication error reporting system was developed, implemented, and evaluated. Data collected were analyzed using descriptive analysis, frequency, percentage, and paired t-test was used to define significance at p<0.05, and root cause analysis.

The results showed , the sample group was 21 people had the knowledge score were increased statistically (10.81±2.84 vs.13.71±1.35, P<0.001) from good to very good . After the developed medication error reporting system was used, there were 78 medication error reports (rate 1.4 times per 100 prescriptions), a 4.7-time increase. The pre-dispensing error was found the most, 52 times (rate 0.9 times per 100 prescriptions). Root cause analysis showed that the majority of medication error  was from not double checking. This study can benefit a more efficient problem prevention system, using information gotten to develop and improve it continually.           

Key words : Medication error , Adverse Drug Event ,Root Cause Analysis