[Show abstract][Hide abstract]ABSTRACT: Hospital pharmacies dispense large numbers of medication doses for hospitalized patients. A study was conducted at an academic tertiary care hospital to characterize the incidence and severity of medication dispensing errors in a hospital pharmacy.
Direct observation of dispensing processes was undertaken to determine presence of errors with review by a physician panel to determine severity.
A total of 140,755 medication doses filled by pharmacy technicians were observed during a seven-month period, and 3.6% (5075) contalned errors. The hospital pharmacist detected only 79% of these errors during routine verification; thus, 0.75% of doses filled would have left the phannacy with undetected errors. Overall, 23.5% of undetected errors were potential adverse drug events (ADEs), of which 28% were serious and 0.8% were life threatening. The most common potential ADEs were incorrect medications (36%), incorrect strength (35%), and incorrect dosage form (21%).
Given the volume of medications dispensed, even a low rate of drug distribution process translates into a large number of errors with potential to harm patients. Pharmacy distribution systems require further process redesign to achieve the highest possible level of safety and reliability.
Full-text · Article · Mar 2006 · Joint Commission journal on quality and patient safety / Joint Commission Resources
[Show abstract][Hide abstract]ABSTRACT: A pharmacy that set up a repackaging center to add a bar code to medication does not already having one concluded that the operation needed a multiple-step quality-control process involving a pharmacy technician and a pharmacist. Lacking the quality-control process, the operation had the potential, despite a low batch-level error rate, to incorrectly package hundreds of doses at a time.
Full-text · Article · Feb 2006 · American Journal of Health-System Pharmacy
[Show abstract][Hide abstract]ABSTRACT: We performed a direct observation prepost study to evaluate the impact of barcode technology on medication dispensing errors and potential adverse drug events in the pharmacy of a tertiary-academic medical center. We found that barcode technology significantly reduced the rate of target dispensing errors leaving the pharmacy by 85%, from 0.37% to 0.06%. The rate of potential adverse drug events (ADEs) due to dispensing errors was also significantly reduced by 63%, from 0.19%to 0.069%. In a 735-bed hospital where 6 million doses of medications are dispensed per year, this technology is expected to prevent about 13,000 dispensing errors and 6,000 potential ADEs per year.