Medication Errors in a Tertiary Hospital With Three Different Drug Delivery Systems

Climent, C.; Font Noguera, I.; Poveda Andrés, J.L.; López Briz, E.; Peiró, S.

doi:10.1016/S2173-5085(08)70025-X

Farmacia Hospitalaria

ISSN: 1130-6343

Farmacia Hospitalaria (Farm Hosp) is the official publication of the Spanish Society of Hospital Pharmacists (SEFH), a professional and scientific organization that currently has about 4.351 members.

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Indexed in:

Web of Science, Scopus, Scimago Journal and Country Rank (SJR), Índice H: 18, CINHAL, EMBASE Excerpta Medica, Índice Bibliográfico Español en Ciencias de la Salud (IBECS), Índice Español de Ciencia Y Tecnología (ICyT), Índice Médico Español (IME), International Pharmaceutical Abstracts (IPA), MEDLINE, DOAJ, Dialnet, Latindex, Medes, Scientific Electronic Library Online (SciELO), REDIB.

Errors were identified from direct observation of 2242 opportunities for error (administered doses or prescribed doses not given) by 6 couples of observers. Delivery medication systems were stock in ward, unit-dose with electronic prescription, and unit dose with computerized transcription. Logistic regression was used to evaluate the association between errors and certain factors.

Results

The medication error rate was 7.2% (95% CI, 6.1–8.3), and 4.4% (95% CI, 3.6–5.3) of them reached the patient. For delivery systems, the error rate was 9.5% (95 CI, 7.4–11.9) for stock in ward, 7.8% (95% CI, 5.9–10.0) for electronic prescription, and 4.7% (95% CI, 3.4–6.4) for computerized transcription. The highest error frequency was observed in the administration phase (58.4%) and the omitted dose was the most prevalent error (31.7%). The error rate was associated with the pharmacotherapeutic process, the schedule of administration, and the unit of hospitalization.

Conclusions

In 1 of each 14 opportunities for error, a medication error takes place. The different delivery medication systems have different error rates.

Keywords:

Medication error

Direct observation

Administration error

Delivery medication systems

Resumen

Objetivo

Estimar la proporción de errores de medicación en un hospital terciario, tanto de manera global como por sistemas de distribución de medicamentos, describir los tipos de error y los medicamentos implicados y analizar los factores asociados a los mismos.

Método

Los errores se identificaron mediante la observación directa de 2.242 oportunidades de error (dosis administradas o las prescritas y no administradas de medicamentos) por 6 pares de observadores. Los sistemas de distribución fueron stock en planta, dosis unitarias con prescripción electrónica asistida y dosis unitarias con transcripción informatizada. Se utilizó la regresión logística múltiple para valorar la asociación entre errores y determinados factores.

Resultados

El porcentaje global de error de medicación fue del 7,2% (IC del 95%, 6,1–8,3), y un 4,4% (IC del 95%, 3,6–5,3) alcanzaron al paciente. Por sistemas de distribución, el porcentaje de error de medicación fue de 9,5% (IC del 95%, 7,4–11,9) para el stock en planta, 7,8% (IC del 95%, 5,9–10,0) para la prescripción electrónica asistida y 4,7% (IC del 95%, 3,4–6,4) para la transcripción informatizada. La mayor frecuencia de errores se observó en la fase de administración (58,4%) y la dosis omitida fue el tipo de error más prevalente (31,7%). El riesgo de error se asoció al proceso farmacoterapéutico, al horario de administración y al tipo de unidad de hospitalización.

Conclusiones

En una de cada 14 oportunidades de error se produce un error de medicación. Los distintos sistemas de administración de medicamentos tienen tasas de error diferentes.

Palabras clave:

Error de medicación

Observación directa

Error de administración

Sistemas de distribución de medicamentos

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