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Frequency, types, and potential clinical significance of medication-dispensing errors

Bohand, Xavier; Simon, Laurent; Perrier, Eric; Mullot, Hélène; Lefeuvre, Leslie; Plotton, Christian

Clinics; v. 64 n. 1 (2009); 11-16

Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo 2009-01-01

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  • Título:
    Frequency, types, and potential clinical significance of medication-dispensing errors
  • Autor: Bohand, Xavier; Simon, Laurent; Perrier, Eric; Mullot, Hélène; Lefeuvre, Leslie; Plotton, Christian
  • Assuntos: Adverse Event; Drug Error; Patient Security; Risk Management; Unit Dose
  • É parte de: Clinics; v. 64 n. 1 (2009); 11-16
  • Descrição: INTRODUCTION AND OBJECTIVES: Many dispensing errors occur in the hospital, and these can endanger patients. The purpose of this study was to assess the rate of dispensing errors by a unit dose drug dispensing system, to categorize the most frequent types of errors, and to evaluate their potential clinical significance. METHODS: A prospective study using a direct observation method to detect medication-dispensing errors was used. From March 2007 to April 2007, "errors detected by pharmacists" and "errors detected by nurses" were recorded under six categories: unauthorized drug, incorrect form of drug, improper dose, omission, incorrect time, and deteriorated drug errors. The potential clinical significance of the "errors detected by nurses" was evaluated. RESULTS: Among the 734 filled medication cassettes, 179 errors were detected corresponding to a total of 7249 correctly fulfilled and omitted unit doses. An overall error rate of 2.5% was found. Errors detected by pharmacists and nurses represented 155 (86.6%) and 24 (13.4%) of the 179 errors, respectively. The most frequent types of errors were improper dose (n = 57, 31.8%) and omission (n = 54, 30.2%). Nearly 45% of the 24 errors detected by nurses had the potential to cause a significant (n = 7, 29.2%) or serious (n = 4, 16.6%) adverse drug event. CONCLUSIONS: Even if none of the errors reached the patients in this study, a 2.5% error rate indicates the need for improving the unit dose drug-dispensing system. Furthermore, it is almost certain that this study failed to detect some medication errors, further arguing for strategies to prevent their recurrence.
  • Títulos relacionados: https://www.revistas.usp.br/clinics/article/view/17870/19935
  • Editor: Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo
  • Data de criação/publicação: 2009-01-01
  • Formato: Adobe PDF
  • Idioma: Inglês
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  • Realização: ABCD-USP USP   Logos de Redes Sociais: Freepik

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