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DD-004 Quality indicators in a unitary dose drug dispensation system: measurement, analysis and improvement
  1. M Llorente Serrano,
  2. C Martí Gil,
  3. L Recuero Galve,
  4. J Sánchez Gundín,
  5. A Mulet Alberola,
  6. D Barreda Hernández
  1. Virgen de La Luz Hospital, Pharmacy, Cuenca, Spain


Background Quality indicators (QIs) are measures of health care quality in order to achieve the planned results in a Quality Management System.

Purpose To evaluate the results of some QIs in a Unitary Dose Drug Dispensation System (UDDDS) in a Hospital Pharmacy Deparment (HPD).

Material and methods Prospective observational 3-weeks study (September ’14) performed in a second level hospital (411 beds, 52.8% of them with UDDDS and manual transcription by nurses and validation by pharmacists). QIs and standars to achieve maximum quality were established by a working group.

  • QI1: %Filling errors = [errors/number of dispensed drugs (nºDD)]*100; SV < 1%

  • QI2: %Transcription errors = [errors/number of prescription lines (nºPL)]*100; SV < 3%

  • QI3: %Validation errors (by a second pharmacist) = [errors/nºPL]*100; SV < 0.5%

  • QI4: %Returns = [returned drugs/nºDD]*100; SV < 5%

Three days a week a “pilot cart” (PC) was selected by a random method (extraction balls) and checked by a pharmacist. Data were recorded and analysed using a form designed for that purpose, Farmatools-Dominion® programme and Microsoft Office Excel®.

Results 9 PC were checked (474 PL, 1736 DD, 207 patients). QIs real values were: QI1 (5.9%); QI2 (8.2%); QI3 (1.4%); QI4 (7.8%). Major error types during filling UDDDS-carts and transcription were treatment omission (44 vs. 11, respectively). Another common errors: a) filling: different amount (26) and commission (16) – drug should be discontinued but remained in patient´s treatment; b) transcription: different dose/dosage regimen (14). The mean causes of returns were: not administered drug (88), transfer/discharge (30) and finished treatment after cart distribution (16).

Conclusion Even though UDDDS may reduce medication errors, the QIs analysed were superior to SV previously defined. The measurement of QIs showed non-compliance and required corrective actions to resolve mistakes in order to improve patient security: regular training sessions for HPD staff, instructive note for nursing, technical instructions for nursing assistant and design of a specific form for returned drugs.

References and/or acknowledgements No.

No conflict of interest.

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