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Drug supply/logistics (including: computeraided drug dispatching and ward pharmacies)
Recording medicines administration errors before introducing new technology
  1. N. Vicente Oliveros,
  2. E. Delgado Silveira,
  3. C. Pérez Menéndez-Conde,
  4. A. Álvarez Díaz,
  5. T. Bermejo Vicedo
  1. 1Hospital Universitario Ramon Y Cajal, Pharmacy Services, Madrid, Spain

Abstract

Background Drug administration is one of the most important stages in the medication process. New technologies are being developed to improve patient safety. The majority of studies focus on administration errors, but evaluation of the impact of administration technology on error rates has lagged behind implementation.

Purpose

  • To classify and quantify the errors in the medication administration record (MAR) before implementing an electronic drug administration record.

  • To identify the main causes of MAR errors.

  • To compare MAR errors detected in a surgical and a medical ward.

Materials and methods An observational and prospective study in a surgical and a medical ward lasting 37 days. Both of them had computerised prescription order entry and an automated dispensing cabinet (ADC). MAR errors were classified according to the taxonomy defined by the Ruiz-Jarabo 2000 group. MAR errors were detected through chart reviews, checking that the administration chart matched the prescription. The day following administration, the pharmacist collected all the information and recorded it on a data sheet.

Results The authors analysed 1,185 doses from 68 patients. The error rate was 15.4%. The most common type of error was failure to record administration (93%). The main cause was procedural failure (66.3%), 52.7% due to incorrect withdrawal of medicines from the ADC. Error rates were higher on the surgical ward (19.5%) than the medical ward (9.4%). This difference was statistically significant (p < 0.001).

Conclusions

  • Failure to record administration was the most common type of MAR error. The main cause was procedural failure, due largely to incorrect withdrawal of medicines from the ADC. There is a need for safe strategies that will reduce errors associated with ADC processes.

  • MAR errors were more common on the surgical ward.

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