Alvarez Díaz AM, 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. [New technologies applied to the medication-dispensing process, error analysis and contributing factors].
FARMACIA HOSPITALARIA 2010;
34:59-67. [PMID:
20206565 DOI:
10.1016/j.farma.2009.12.003]
[Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 12/18/2009] [Accepted: 12/21/2009] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE
Calculate error prevalence occurred in different medication-dispensing systems, the stages of occurrence, and contributing factors.
METHODOLOGY
Prospective observational study. The staging of the dispensing process were reviewed in five dispensing systems: Stock, Unitary-Dose dispensing systems (UDDS) without Computerized 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
2,181 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-CPOE-UDDS 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.
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