Quality of Drug Treatment Process Through Medication Errors in a Tertiary Hospital

Font Noguera, I.; Climent, C.; Poveda Andrés, J.L.

doi:10.1016/S2173-5085(08)70047-9

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:
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- 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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A prospective, observational study into medication errors was carried out on 308 hospitalized patients. This was done by assessing medical prescriptions, pharmaceutical validation, prepared and dispensed medication, and by directly observing drug administration. The variable, ie, the medication error, was analyzed in the drug treatment process so as to decipher the type and cause of the error. Quality indicators were defined at each stage (percentage relationship between errors and opportunities for error).

Results

Of the 308 patients studied, 107 had at least 1 medication error (34.7%). There were a total of 137 errors: omission of allergy and prescription description (20.4%), prescription/validation (28.5%), dispensing (23.4%), and drug administration (27.7%). The most frequent error was dose omission (19.7%) and choice of pharmaceutical product (16.1%). The most common cause of error was forgetfulness or a lack of attention to detail (53.3%). The quality indicators by stage were: 2.3% for omission of the patient's allergies; 0.9% for prescription; 1.6% for prescription/validation; 8.2% for dispensing; and 2.1% for drug administration.

Conclusions

It is estimated that 35 patients in every 100 experience errors in their drug treatment process. Opportunities for improvement are identified based on standardization and training for professionals in carrying out technical tasks and using technology.

Key words:

Medication error

Direct observation

Administration error

Drug distribution systems

Drug treatment process

Objetivo

Evaluar la calidad del proceso farmacoterapéutico en un sistema de dosis unitaria y prescripción electrónica asistida en un hospital terciario, a través de errores de medicación.

Métodos

Se realizó un estudio observacional prospectivo de errores de medicación en 308 pacientes hospitalizados, por revisión de la prescripción médica, la validación farmacéutica y la medicación preparada y dispensada, y por observación directa de la administración de medicamentos. La variable, el error de medicación, se analizó en la fase del proceso farmacoterapéutico, el tipo y la causa de error. Se definieron indicadores de calidad (relación porcentual de errores respecto a oportunidades de error) en cada fase.

Resultados

De los 308 pacientes estudiados, en 107 se detectó al menos 1 error de medicación (34,7%); hubo un total de 137 errores distribuidos en: omisión de alergia y descripción de la prescripción (20,4%), prescripción/validación (28,5%), dispensación (23,4%) y administración de medicamentos (27,7%). El error más frecuente fue la omisión de dosis (19,7%) y la selección de especialidad farmacéutica (16,1%). La causa más común fue fallos de memoria y descuidos con el 53,3%. Los indicadores de calidad por fases fueron: 2,3% para la omisión de alergia del paciente; 0,9% para la prescripción; 1,6% para la prescripción/validación; 8,2% para la dispensación, y 2,1% para la administración de medicamentos.

Conclusiones

Se estima que en 35 de 100 pacientes ocurre un error en su proceso farmacoterapéutico. Se identifican oportunidades de mejora basadas en la normalización y la formación de profesionales para realizar tareas técnicas y manejar la tecnología.

Palabras clave:

Error de medicación

Observación directa

Error de administración

Sistemas de distribución de medicamentos

Proceso farmacoterapéutico

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References

[1.]

Grupo, GEPEM., (Grupo Español para la Prevención de Errores de Medicación).

Mejora de la seguridad del sistema de utilización de medicamentos: funciones del especialista en farmacia hospitalaria.

Farm Hosp, 29 (2005), pp. 384-388

Medline

[2.]

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

Errores de medicación en un hospital terciario con tres sistemas de distribución diferentes.

Farm Hosp, 32 (2008), pp. 18-24

Medline

[3.]

P. Blasco Segura, E. Mariño, M. Aznar Saliente, E. Pol Yanguas, M. Alós Almiñana, M. Castells Molina, et al.

Desarrollo de un método observacional prospectivo de estudio de errores de medicación para su aplicación en hospitales.

Farm Hosp, 25 (2001), pp. 253-273

[4.]

E. Tissot, C. Cornette, S. Limat, J.L. Mourand, M. Becker, J.P. Etievent, et al.

Observational study of potential risk factors of medication administration errors.

Pharm World Sci, 25 (2003), pp. 264-268

Medline

[5.]

B. Dean Franklin, C. Vincent, M. Schachter, N. Barber.

The incidence of prescribing errors in hospital inpatients: an overview of the research methods.

Drug Saf, 28 (2005), pp. 891-900

Medline

[6.]

N.V. Jiménez Torres, M. Climente Martí, I. Font Noguera.

Guía para la práctica clínica orientada a problemas farmacoterapéuticos.

1st ed., APHPE. Hospital Universitario Dr. Peset;, (2002),

[7.]

E. García Cortés, A. Rodrigo, J.A. Carbajal, P.M. Carmona, I. Font.

Sistema de distribución individualizada de medicamentos por dosis unitarias: análisis global de la calidad en un hospital terciario.

Rev Calidad Asistencial, 16 (2001), pp. 384-389

[8.]

L.L. Leape, D.W. Bates, D.J. Cullen, J. Cooper, H.J. Demonaco, T. Gallivan, et al.

Systems analysis of adverse drug events ADE Prevention Study Group.

JAMA, 274 (1995), pp. 35-43

Medline

[9.]

O. Delgado Sánchez, A. Escrivá Torralba, J. Serrano López de las Hazas, M. Crespí Monjo, M. Pinteño Blanco, et al.

Estudio comparativo de errores con prescripción electrónica versus prescripción manual.

Farm Hosp, 29 (2005), pp. 228-235

Medline

[10.]

V. Llodrá Ortolá, M.A. Morey Riera, X. Perelló Roselló, X. Vaquer Sunyer.

Acreditación de un Servicio de Farmacia según la norma ISO 9002 Experiencia en la Fundación Hospital Manacor.

Farm Hosp, 25 (2001), pp. 229-239

[11.]

S. Jornet Montaña, L. Canadell Vilarrasa, M. Calabuig Muñoz, G. Riera Sendra, M. Vuelta Arce, A. Bardají Ruiz, et al.

Detección y clasificación de errores de medicación en el Hospital Universitari Joan XXIII.

Farm Hosp, 28 (2004), pp. 90-96

Medline

[12.]

P.J. Ambrose, F.G. Saya, L.T. Lovett, S. Tan, D.W. Adams, R. Shane.

Evaluating the accuracy of technicians and pharmacists in checking unit dose medication cassettes.

Am J Health Syst Pharm, 59 (2002), pp. 1183-1188

Medline

[13.]

P.F. Griner.

Leadership strategies of medical School Deans to promote quality and safety.

Jt Comm J Qual Improv, 33 (2007), pp. 63-72

[14.]

S.P. Desselle.

Certified pharmacy technicians’ views on their medication preparation errors and educational needs.

Am J Health Syst Pharm, 62 (2005), pp. 1992-1997

[15.]

E.G. Poon, J.L. Cina, W. Churchill, N. Patel, E. Featherstone, J.M. Rothschild, et al.

Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy.

Ann Intern Med, 145 (2006), pp. 426-434

Medline

[16.]

K. Skibinski, B.A. White, L.I. Lin, Y. Dong, W. Wu.

Effect of technological interventions on the safety of a medication use system.

Am J Health Syst Pharm, 64 (2007), pp. 90-96

http://dx.doi.org/10.2146/ajhp060060 | Medline

[17.]

M.J. Otero, C. Codina, D. Robles.

Programa multidisciplinario de prevención de errores de medicación en un hospital.

Rev Calidad Asistencial, 20 (2005), pp. 79-89

[18.]

A. Frankel, S.P. Grillo, E.G. Baker, C.N. Huber, S. Abookire, M. Grenham, et al.

Patient Safety Leadership WalkRounds at Partners Healthcare: learning from implementation.

Jt Comm J Qual Improv, 31 (2005), pp. 423-437

[19.]

P.J. Kaboli, A. Hoth, B.J. McClimon, J.L. Schnipper.

Clinical pharmacists and inpatient medical care. A systematic review.

Arch Intern Med, 166 (2006), pp. 955-964

http://dx.doi.org/10.1001/archinte.166.9.955 | Medline

[20.]

F. Borrell-Carrió, clínica. Ética de la seguridad.

Contribuciones desde la práctica médica.

Med Clin (Barc), 129 (2007), pp. 176-183

[21.]

B. Lo, M. Groman.

Oversight of quality improvement.

Focusing on benefits and risks. Arch Intern Med, 163 (2003), pp. 1481-1486

☆

Preliminary statement of publication: Preliminary results of the research project were presented as a poster in the 25th Conference of the Spanish Society for Quality Assistance, celebrated in Barcelona, October 17-19, 2007.

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