New technologies applied to the medication-dispensing process, error analysis and contributing factors

Álvarez Díaz, A.M.; Delgado Silveira, E.; Pérez Menéndez-Conde, C.; Pintor Recuenco, R.; Gómez de Salazar López de Silanes, E.; Serna Pérez, J.; Mendoza Jiménez, T.; Bermejo Vicedo, T.

doi:10.1016/S2173-5085(10)70001-0

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.

The Mission of Farm Hosp is to be the support for health professionals for expanding the influence of projects, publications, and training programs, and to promote the exchange of experiences.

Vision Farm Hosp is:
- to increase the state of knowledge about the hospital pharmacy and whose actions should increase the adequate and safe use of medicines and health products.
- to be an instrument of exchange and dissemination of scientific knowledge of pharmacy practice through the best use and safe medication and health outcomes.

It is a peer-reviewed double-blind scientific journal aimed at publishing in the broad field of Hospital Pharmacy advances in Pharmacy Services. This journal included the following topics: Drug evaluation. Quality of life. Patient Reported Outcome Measures (PROMs), and Patient Reported Experience Measures (PREMs) in the use of drugs. Monitoring medication. Pharmaceutical compounding. Medication administration. Management of Pharmacy Services (logistics, quality control). Technologies and information systems in the process of using medication. Medical devices. Patient Education. Pharmacist´s role in the society and /or in the Health System in Spain, and other topics related to clinical, scientific, and institutional role of hospital pharmacists.

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All the articles are published in Spanish and English language regardless of the language in which they are received.

Farmacia Hospitalaria is an Open Access journal, whose content is available free of charge to users or their institutions. Users are authorised to read, download, copy, distribute, print, search, or link to entire texts of the articles in this journal without prior permission from the editor or author, according to the BOAI definition of Open Access. The papers may be re-used under the terms of the Creative Commons 4.0 license. (CC BY-NC-ND). Such use shall be subject to authorisation from SEFH, the journal owner.

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Indexed in:

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Prospective observational study. The staging of the dispensing process were reviewed in five dispensing systems: Stock, Unitary-Dose dispensing systems (UDDS) without Computerised Prescription Order Entry (CPOE), CPOE-UDDS, Automated Dispensing Systems (ADS) without CPOE and CPOE-ADS. Dispensing errors were identified, together with the stages of occurrence of such errors and their contributing factors.

Results

Two thousand one hundred eighty one errors were detected among 54,169 opportunities of error. Error-rate: Stock, 10.7%; no-CPOE-UDDS, 3.7%, CPOE-UDDS, 2.2%, no-CPOE-ADS, 20.7%; CPOE-ADS, 2.9%. Most frequent stage when error occurs: Stock, preparation of order; no-CPOEUDDS and CPOE-UDDS, filling of the unit dose cart; no-CPOE-ADS and CPOE-ADS, filling of the ADS. Most frequent error: Stock, no-CPOE-ADS and CPOE-ADS, omission; CPOE-UDDS, different amount of drug and no-CPOE-UDDS, extra medication. Contributing factor: Stock, CPOE-ADS and no-CPOE-ADS, stock out/supply problems; CPOE-UDDS, inexperienced personnel and deficient communication system between professionals; no-CPOE-UDDS, deficient communication system between professionals.

Conclusions

Applying new technologies to the dispensing process has increased its safety, particularly, implementation of CPOE has enabled to reduce dispensing errors.

Keywords:

Dispensing errors

Medication error

Medication-dispensing systems

Pharmaco-therapeutic process

Quality

Resumen

Objetivo

Calcular la prevalencia de los errores producidos en diferentes sistemas de dispensación de medicamentos, las etapas en que se producen y los factores contribuyentes.

Métodos

Estudio observacional prospectivo. Se revisaron las etapas del proceso de dispensación en 5 sistemas de dispensación: stock o botiquín de planta, sistema de distribución de medicamentos en dosis unitaria (SDMDU) sin prescripción electrónica asistida (PEA), SDMDU con PEA, sistema automatizado de dispensación (SAD) sin PEA y SAD con PEA. Se identificaron los errores de dispensación, las etapas en que ocurrieron dichos errores y sus factores contribuyentes.

Resultados

De 54.169 oportunidades de error, se detectaron 2.181 errores. Tasa de error: stock, 10,7%; SDMDU sin PEA, 3,7%; SDMDU con PEA, 2,2%; SAD sin PEA, 20,7%; SAD con PEA, 2,9%. Etapa más frecuente en la que se produce el error: stock, preparación del pedido; SDMDU sin PEA y con PEA, llenado del carro; SAD sin PEA y con PEA, llenado del SAD. Error más frecuente: stock, SAD sin PEA y con PEA, omisión; SDMDU con PEA, diferente cantidad de medicamento; SDMDU sin PEA, sobra medicamento. Factor contribuyente: stock, SAD sin PEA y con PEA, rotura de stock/desabastecimiento; SDMDU con PEA, personal sin experiencia y sistema de comunicación deficiente entre profesionales; SDMDU sin PEA, sistema de comunicación deficiente entre profesionales.

Conclusiones

La aplicación de nuevas tecnologías en el proceso de dispensación ha aumentado su seguridad, concretamente la implantación de la PEA ha permitido disminuir los errores en el proceso de dispensación.

Palabras clave:

Error de dispensación

Error de medicación

Sistemas de distribución de medicamentos

Proceso farmacoterapéutico

Calidad

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