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2SPD-024 Unit dose system evaluation
  1. G Gonzalez Morcillo,
  2. A Oliver,
  3. JM Rodriguez,
  4. M Vilanova,
  5. F Company,
  6. V Cano,
  7. A Mandilego
  1. Son Llatzer Hospital, Pharmacy Department, Palma de Mallorca, Spain


Background The unit dose system of medication distribution is a pharmacy-coordinated method of dispensing and controlling medication in an organised healthcare settings. In our hospital, medications contained in single unit package are delivered for a 24 hour period. However, many drugs are requested and returned to the pharmacy store.

Purpose To identify the reasons for requested and returned drugs dispensed by a unit dose system.

Material and methods Prospective study over a 6 month period, in which drugs dispensed returned from various clinical units and were analysed. The study presented two stages. The first one, a medication cart was randomly selected once a week and double-checked before dispensing: the medication errors were recorded and corrected before it was taken to the relevant hospital ward. The second step was to monitor the medication cart during 24 hours after delivering. The requested and returned medication to the Pharmacy Department from the clinical unit selected was recorded and analysed with the nursing staff. To data, a standardised sheet was elaborated, which will allow us to record the clinical unit studied, and the different discrepancies related to the drugs’ dispensing process.

Results During the study, 24 medication carts were assessed, including 3766 medication lines and 6796 unit doses, corresponding to 572 patients. Thirty-eight medication lines errors (1%) were detected at the Pharmacy Department. The most frequent error was dose duplication, 17 cases were registered (50%) and its main cause was the lack of attention, 13 records (73.6%). One hundred and forty-four medication requests, which correspond to 204 unit doses, were registered. The main cause was because of treatment modification/new prescription, 77 occasions (38.2%), followed by the new hospitalised patients, 53 cases (25.7%): 1127 unit doses (16.58%) were returned to the Pharmacy Department mainly due to drugs that must be administered only in some situations such as pain or fever: 604 unit doses were registered for this cause (53.5%).

Conclusion This study has allowed the identification of the main cause of errors in the medication dispensing process. Knowing the failures of the unit dose system will allow us to design the dispensing circuit to increase their efficiency.

References and/or Acknowledgements Nursing staff of Son Llatzer Hospital.

No conflict of interest

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