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PS-038 Review of drug prescription errors reported to the Health Department of the Madrid Autonomous Community
  1. A Ibáñez Zurriaga,
  2. MA Ruíz Gómez,
  3. E Ramirez Herraíz,
  4. E Deben Tiscar,
  5. M Pérez Abanades,
  6. JM Serra López-Matencio,
  7. E Alañón Plaza,
  8. T Gallego Aranda,
  9. C Martinez Nieto,
  10. A Morell Baladrón
  1. Hospital Universitario de la Princesa, Pharmacy, Madrid, Spain

Abstract

Background In 2005, the Safe Use of Drug and Health Products website was launched by the Health Department of the Madrid Autonomous Community. Any health professional can communicate drug prescription errors detected through Functional Risk Management Units (UFR).

Patient safety is a strategic guideline used. Considering that the drug treatment is one of the most widely used health services, and one of the most complex and effective, in terms of technology, attention needs to be given to this point and to its safe use.

Purpose To analyse the medicines errors submitted from the Pharmacy Service to the UFR, to identify and prioritise actions for improvement.

Materials and methods The submissions made through an online formulary to the Safe Use of Drug and Health Products website were analysed from September 2011 to September 2013.

  • From all items of the formulary, we collected: error type, patient consequences, stage of the process and place where it happened.

  • Error notification is anonymous and confidential.

Results During the study, 159 errors were reported. Regarding the process stage: 135 (84.9%) during prescription, 13 (8.2%) while dispensing, 3 (1.88%) during manufacture, 3 (1.88%) during administration, 3 (1.88%) during labelling, 1 (0.63%) during validation and 1 (0.63%) during transcription. Concerning the type of error: 54 (33.96%) were due to a dose error, 25 (15.72%) to an administration frequency error, 22 (13.83%) due to a drug selection error, 12 (6.92%) due to a dispensing error, 8 (5%) due to a manufacturing error, 4 (2.5%) due to dispensing to the wrong patient, 3 (1.8%) due to a treatment length error and 3 (1.8%) due to a lack of drug quality. Regarding the consequences for the patient: 70 (44%) didn’t reach the patient; of the 69 (43.3%) events that could have caused an error, 17 (10.7%) reached the patient with no damage, 2 (1.2%) harm was done but was impossible to trace, 1 (1.72%) monitoring was required. Concerning the unit where the error took place: 111 (69.8%) in the hospital plant, 23 (14.5%) in the Pharmacy Service, 18 (11.3%) in the Urgency Service and 8 (5%) in other units.

Conclusions Recording and categorising the drug errors provides the most accurate information about which points must be improved regarding the complex process of drug use. A lot of drug errors occur during the prescription but most of them do not reach the patients. The errors prompt us to continue improving the electronic validation of prescriptions, as well as future actions in other areas.

No conflict of interest.

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