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PS-085 Impact of drug incident reporting on the work of pharmaceutical services
  1. D Palma1,
  2. C Coutinho1,
  3. C Rocha1,
  4. S Valongo1,
  5. A Simões2
  1. 1Hospital Dr. José de Almeida, Pharmacy, Cascais, Portugal
  2. 2Hospital Dr. José de Almeida, Quality Department, Cascais, Portugal

Abstract

Background The growing introduction of new therapeutic options has contributed to increased awareness of patient safety in Health Care. Different studies have quantified the medication errors that take place at every step of the medicines use process.

Purpose To evaluate the impact of drug incident reporting on the way the Pharmaceutical Services (PS) work.

Material and methods Retrospective study, 2011–2014, of the drugs-related incident reports recorded on the Incidents Reporting Platform (IRP). All notifications were assessed regarding the stage of the medication process, root-cause analysis and categorising of medicines.

These incidents were assessed in the PS and corrective or preventive actions taken according to ISO 9001:2008 by the Quality Department.

Results 425 incident reports were recorded on the IRP, 45 (10.6%) regarding drugs. Of these, 73.3% were related to the dispensing process, 4.4% to preparation, 17.8% to drug administration and 4.4% to patient identification.

Most incidents are potential errors that are detected early and do not reach the patient, considered near misses (JCI).1 The drugs involved were look-alike sound-alike (LASAs), β-lactams and amiodarone. The most frequent causes related to drug dispensing (73.3%) were omission of a medicine (36.4%) and wrong medicine (21%).

Conclusion Reporting systems (RS) are a key element for building a culture of safety. RS are useful if data is assessed and information is provided back to the health professionals involved. Following the assessment of these reports improvements have been implemented in the drug circuit: change in the location, confirmation before dispensing (random or total), and random weekly audits of medicines repackaged at the Pharmacy warehouse facilities. Study limitations include the absence of reports related to prescriptions, which should be encouraged in order to improve safety.

Reference

  1. Joint Commission International Accreditation Standards for Hospitals, 5th ed. JCI, April 2014

ReferenceNo conflict of interest.

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