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5PSQ-101 Medication errors in unit-dose drug distribution system: quality control
  1. Z Rodríguez Fernández,
  2. S Llamas Lorenzana,
  3. P González Pérez,
  4. X Casás Fernández,
  5. A Vélez Blanco,
  6. C De Castro Avedillo,
  7. JC Saez Hortelano,
  8. R Varela Fernández,
  9. E Martínez Álvarez,
  10. N Álvarez Núñez,
  11. JJ Ortiz De Urbina González
  1. León University Hospital, Hospital Pharmacy, León, Spain


Background and importance The need to improve the quality of the unit-dose dispensing system was detected due to an increase in errors.

Aim and objectives Quantitative and qualitative analysis of errors in the dispensing of unit-dose drugs to implement measures to reduce them.

Material and methods Prospective study, 2 months duration, in a tertiary hospital. The drug trolleys of two randomised nursing units were chosen from 16 hospitalisation units (589 beds) where unit-dose dispensing was reviewed daily. The review was conducted by a pharmacist and a pharmacy technician, using a protocol for quality control of the unit-dose dispensing system, which is based on the comparison of medication listings per patient with the drug content of the drug trolleys. Finally, the pharmacist makes a quantitative analysis: number and error rate (number of dispensing errors for every 100 changes); and qualitative analysis: type of error. The data obtained are analysed monthly.

Results 247 dispensing errors were detected, with a mean of 2823 (±124) revised changes per day. The median error rate was 1.23 (IR 0.48–1.99), the first month being 1.61 (IR 1.13–3.07), and 0.45 (IR 0–0.91) in the second month. The median error rate in the manually filled plants was 1.56 (IR 0.67–2.21) versus 0.92 (IR 0.57–1.24) in trolleys dispensed by automated dispensing cabinets. Filling the drug trolleys with an incorrect number of units was the most repeated error (44.13%, n=109), followed by the omission of introducing a medication (17.81%, n=44) and introducing a medication not prescribed (13.77%, n=34).

Conclusion and relevance From the error analysis we can conclude that:

  1. A reduction in potential dispensing errors was achieved, as the error rate decreased from 1.94 to 0.59 from the first to the second month.

  2. Increasing automated dispensing cabinets could help reduce errors, as plants filled without the help of electronic systems have a higher error rate (1.34 vs 1.16).

  3. There is a need to educate the pharmacy technicians about the impact of their work on the safety of hospitalised patient care, insisting on the need to check the number and name of the drugs introduced.

Conflict of interest No conflict of interest

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