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DD-025 Automatic storage system: Impact in reducing medication errors in a paediatric hospital
  1. F Bossacoma Busquets,
  2. M Sánchez Celma,
  3. A Comes Escoda,
  4. J Arrojo Suárez,
  5. A Mas Comas,
  6. M Coto Moreno,
  7. M Rodríguez Cayuela,
  8. JM Català Foguet,
  9. R Farré Riba
  1. Hospital Sant Joan de Déu, Pharmacy, Espluques de Llobregat, Spain


Background An automatic storage and picking system linked to the electronic prescription was introduced into the pharmacy of our children’s university hospital. The pharmacy prepares and distributes unit dose patient specific medication to 213 paediatric inpatients on a daily basis. Safety is one the most important objectives in our hospital, so automation of the pharmacy was introduced in order to increase it.

Purpose The aim of this study was to determine whether dispensing errors were reduced in preparing daily unit dose drugs in a paediatric hospital after the introduction of an automated storage system in comparison with traditional manual picking.

Material and methods Data were collected over 2 months by checking the whole amount of medication units contained in every patient’s daily unit dose (dispensed in an individual container) before sending them to wards. It was done a month prior to the introduction of the automated storage system and the same month once the system was fully implemented. We used a chart to register every incident detected and classify it as: wrong medicine, wrong dosage, wrong pharmaceutical form, wrong patient container, excess of units or missing units.

Results A total of 30 114 units were analysed, 17 062 of which were checked before the automated storage system was implemented in the pharmacy, and the rest (13 052 units) were examined after its implementation. Recorded errors were 186 (1.09% regarding the total units dispensed) in the first stage, before automation, and 41 (0.31%) in the second stage, after automation, resulting in a risk ratio of 3.52.

Analysing the type of errors, it is important to remark that wrong medicine and wrong dosage were dramatically reduced, whereas the excess of units remained steady.

Conclusion By implementing this automatic storage and picking system, patient safety has increased on account of the decrease in the number of dispensing errors made. Indeed, we have been able to reduce those errors related to dispensing the wrong medicine or dosage, which are the most hazardous and likely to happen in a paediatric hospital owing to the large number of available pharmaceutical forms and dosages for the same drug.

References and/or Acknowledgements Acknowledgements to Juan Antonio and to all of the pharmacy staff.

No conflict of interest.

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