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DD-013 Dispensing errors in inpatients and impact of pharmaceutical intervention
  1. M Ferrit Martín,
  2. T Simon Sanchez,
  3. M Carrasco Gomariz,
  4. A Jimenez Morales,
  5. SI Garcia Dominguez,
  6. MA Calleja Hernandez
  1. University Hospital Virgen de Las Nieves, Pharmacy Service, Granada, Spain


Background The process of distributing drugs to hospitalised patients is complex, which is why it is necessary to establish improvement strategies in hospitals to ensure patient safety, monitoring every point in the process of the distribution of drugs: prescription, validation, preparation and dispensing.1

Purpose To detect and analyse medication errors (ME) in dispensing inpatients. To assess the impact of pharmaceutical intervention after implementation of corrective measures.

Material and methods Follow-up study pre-post intervention (pre-intervention phase: October 2014 to June 2014 and post-intervention phase: March 2014 to November 2015). The intervention involved implementation of corrective measures in the distribution system of drugs in unit doses to improve the safety of hospital patients. These corrective measures were aimed at all healthcare professionals involved. Corrective measures were: incorporating medication carts (MC) with safety systems, implementing protocols for filling and emptying of MC and implementation of a medication dispensing protocol omitted from clinical units. The amount (%) and type of ME were compared before and after the implementation of corrective measures. Monitoring of ME in dispensing was performed by daily selection of 5 MC.

Results 160 medication carts (80 pre-intervention phase and 80 post-intervention phase) and 31 360 (15 102 pre-intervention phase and 16 258 post-intervention phase) treatment lines were monitored. 13.10% and 4.37% of ME in the pre-intervention and post-intervention phases were detected, respectively. 5 types of ME were detected in the pre-intervention phase (4.98% missing drugs, 4.71% non-prescription drugs, 2.62% excess drugs, 0.65% deficit drugs, 0.14% repackaging) and 3 in the post-intervention phase (2.18% missing drugs, 1.44% deficit drugs, 0.75% excess drugs). We obtained a reduction in ME of -8.73%. A decrease was observed in ME non-prescription drugs, 88 (-4.71%) and ME with excessive drugs (-1.97%).

Conclusion The main medication errors detected during filling corresponded to missing drugs and excessive drugs. The implementation of standardised protocols in dispensing drugs in individualised doses reduces medication errors and increases safety for hospitalised patients.

References and/or Acknowledgements

  1. Ka-Chun Cheung, et al. Medication errors: the importance of safe dispensing. Br J Clin Pharmacol 2009;67:676–80

References and/or AcknowledgementsNo conflict of interest.

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