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PS-004 Efficacy of a closed loop medicines administration process to reduce the probability of medicines errors
  1. M Baehr,
  2. A Van der Linde,
  3. R König,
  4. S Melzer,
  5. C Langebrake
  1. Universitätsklinikum Hamburg Eppendorf, Apotheke, Hamburg, Germany


Background Medicines errors are common, costly, and responsible for clinically important problems. The main error-prone process steps are prescription, transcription, dispensing and administration. Different strategies to prevent medicines errors like implementation of computerised physician order entry (CPOE), pharmacy validation, unit-dose supply, and barcoding at point of care are discussed. With a combination of different strategies a closed loop of medicines administration can be achieved, which should be most efficient to prevent medicines errors.

Purpose To evaluate the efficacy of a closed loop medicines administration process as designed at University Medical Centre Hamburg Eppendorf to reduce the probability of medicines errors.

Materials and methods 3,111 medicines for oral use were checked shortly before administration on two different wards (oncology and neurosurgery). The medicines were checked with respect to 12 quality criteria defined by Groth-Tonberge et al 1: right order, right patient, identity, dosage form, strength, light and moisture-protection, date of expiry, correct crushing, dose, daily dose, time of administration.

Results Overall 3,111 medicines were analysed. 2,981 (95.6%) were unit doses delivered by the pharmacy, 130 (4.4%) were manually dispensed by nurses (PRN medicines etc.). In ward A 1,640 medicines were checked, revealing 41 deviations (error rate 2.5%). 16 deviations referred to unit-dose medicines (error rate 1.0%) and 25 discrepancies were noted in the manual supply (error rate 48.1%). In ward B 1,471 medicines were checked, 8 discrepancies were observed (error rate of 0.5%). 5 deviations referred to unit-dose medicines (error rate 0.4%) and 3 deviations were found with manually dispensed medicines (error rate 3.8%).

Conclusions The observed error rates were significantly lower than those recognised in a comparable study* which was done in a hospital where CPOE without unit-dose distribution was implemented. Due to the fact that a deviation does not necessarily generate a medicines error, the very low rate of deviations observed in this study shows that the probability of the occurrence of errors is significantly reduced by a closed loop medicines administration process.


  1. Groth-Tonberge C, Häckh G, Strehl E, Hug, M. Führt die elektronische Verordnung zu einer höheren Arzneimitteltherapiesicherheit? Krankenhauspharmazie 2012;33: 476-9

No conflict of interest.

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