BIOMAT Database Logo BIOMAT Database Logo

[Monitoring medication errors in personalised dispensing using the Sentinel Surveillance System method]. 2011

M Pérez-Cebrián, and I Font-Noguera, and L Doménech-Moral, and V Bosó-Ribelles, and P Romero-Boyero, and J L Poveda-Andrés
Servicio de Farmacia, Hospital Universitario La Fe, Valencia, España. perez_maceb@gva.es

OBJECTIVE To assess the efficacy of a new quality control strategy based on daily randomised sampling and monitoring a Sentinel Surveillance System (SSS) medication cart, in order to identify medication errors and their origin at different levels of the process. METHODS Prospective quality control study with one year follow-up. A SSS medication cart was randomly selected once a week and double-checked before dispensing medication. Medication errors were recorded before it was taken to the relevant hospital ward. Information concerning complaints after receiving medication and 24-hour monitoring were also noted. Type and origin error data were assessed by a Unit Dose Quality Control Group, which proposed relevant improvement measures. RESULTS Thirty-four SSS carts were assessed, including 5130 medication lines and 9952 dispensed doses, corresponding to 753 patients. Ninety erroneous lines (1.8%) and 142 mistaken doses (1.4%) were identified at the Pharmacy Department. The most frequent error was dose duplication (38%) and its main cause inappropriate management and forgetfulness (69%). Fifty medication complaints (6.6% of patients) were mainly due to new treatment at admission (52%), and 41 (0.8% of all medication lines), did not completely match the prescription (0.6% lines) as recorded by the Pharmacy Department. Thirty-seven (4.9% of patients) medication complaints due to changes at admission and 32 matching errors (0.6% medication lines) were recorded. The main cause also was inappropriate management and forgetfulness (24%). The simultaneous recording of incidences due to complaints and new medication coincided in 33.3%. In addition, 433 (4.3%) of dispensed doses were returned to the Pharmacy Department. After the Unit Dose Quality Control Group conducted their feedback analysis, 64 improvement measures for Pharmacy Department nurses, 37 for pharmacists, and 24 for the hospital ward were introduced. CONCLUSIONS The SSS programme has proven to be useful as a quality control strategy to identify Unit Dose Distribution System errors at initial, intermediate and final stages of the process, improving the involvement of the Pharmacy Department and ward nurses.

UI MeSH Term Description Entries
D008508 Medication Errors Errors in prescribing, dispensing, or administering medication with the result that the patient fails to receive the correct drug or the indicated proper drug dosage. Drug Use Error,Errors, Medication,High-Alert Drug Error,High-Alert Medication Error,LASA Medication Errors,Look-Alike Drug Name Errors,Look-Alike Sound-Alike Drug Errors,Look-Alike Sound-Alike Drug Substitution Errors,Look-Alike Sound-Alike Medication Errors,Lookalike Drug Name Errors,Lookalike Soundalike Drug Errors,Lookalike Soundalike Drug Substitution Errors,Lookalike Soundalike Medication Errors,Drug Error, High-Alert,Drug Use Errors,Error, Drug Use,Error, LASA Medication,Error, Medication,High Alert Drug Error,High Alert Medication Error,High-Alert Drug Errors,High-Alert Medication Errors,LASA Medication Error,Look Alike Drug Name Errors,Look Alike Sound Alike Drug Errors,Look Alike Sound Alike Drug Substitution Errors,Look Alike Sound Alike Medication Errors,Medication Error,Medication Error, High-Alert,Medication Error, LASA,Medication Errors, High-Alert,Medication Errors, LASA
D008510 Medication Systems, Hospital Overall systems, traditional or automated, to provide medication to patients in hospitals. Elements of the system are: handling the physician's order, transcription of the order by nurse and/or pharmacist, filling the medication order, transfer to the nursing unit, and administration to the patient. Hospital Drug Distribution Systems,Hospital Medication System,Hospital Medication Systems,Medication System, Hospital,Drug Distribution System, Hospital,Drug Distribution Systems, Hospital,Hospital Unit Dose Drug Distribution System,Hospital Unit Dose Drug Distribution Systems,System Hospital Medication,Systems, Medication Hospital,Hospital Medication, System,Hospital Medications, System,Hospital System, Medication,Hospital Systems, Medication,Medication Hospital System,Medication Hospital Systems,Medication, System Hospital,Medications, System Hospital,System Hospital Medications,System, Hospital Medication,System, Medication Hospital,Systems, Hospital Medication
D010355 Patient Identification Systems Organized procedures for establishing patient identity, including use of bracelets, etc. Patient Tracking,Identification System, Patient,Identification Systems, Patient,Patient Identification System,Patient Trackings,System, Patient Identification,Systems, Patient Identification,Tracking, Patient,Trackings, Patient
D010607 Pharmacy Service, Hospital Hospital department responsible for the receiving, storing, and distribution of pharmaceutical supplies. Clinical Pharmacy Service,Hospital Pharmacy Service,Pharmacy Service, Clinical,Hospital Pharmaceutic Service,Hospital Pharmaceutical Service,Hospital Pharmacy Services,Pharmaceutic Service, Hospital,Pharmaceutical Service, Hospital,Service, Clinical Pharmacy,Service, Hospital Pharmaceutic,Service, Hospital Pharmaceutical,Service, Hospital Pharmacy,Clinical Pharmacy Services,Hospital Pharmaceutic Services,Hospital Pharmaceutical Services,Pharmaceutic Services, Hospital,Pharmaceutical Services, Hospital,Pharmacy Services, Clinical,Pharmacy Services, Hospital,Services, Clinical Pharmacy,Services, Hospital Pharmaceutic,Services, Hospital Pharmaceutical,Services, Hospital Pharmacy
D011446 Prospective Studies Observation of a population for a sufficient number of persons over a sufficient number of years to generate incidence or mortality rates subsequent to the selection of the study group. Prospective Study,Studies, Prospective,Study, Prospective
D011786 Quality Control A system for verifying and maintaining a desired level of quality in a product or process by careful planning, use of proper equipment, continued inspection, and corrective action as required. (Random House Unabridged Dictionary, 2d ed) Control, Quality,Controls, Quality,Quality Controls
D004364 Pharmaceutical Preparations Drugs intended for human or veterinary use, presented in their finished dosage form. Included here are materials used in the preparation and/or formulation of the finished dosage form. Drug,Drugs,Pharmaceutical,Pharmaceutical Preparation,Pharmaceutical Product,Pharmaceutic Preparations,Pharmaceutical Products,Pharmaceuticals,Preparations, Pharmaceutical,Preparation, Pharmaceutical,Preparations, Pharmaceutic,Product, Pharmaceutical,Products, Pharmaceutical
D005500 Follow-Up Studies Studies in which individuals or populations are followed to assess the outcome of exposures, procedures, or effects of a characteristic, e.g., occurrence of disease. Followup Studies,Follow Up Studies,Follow-Up Study,Followup Study,Studies, Follow-Up,Studies, Followup,Study, Follow-Up,Study, Followup
D005568 Forms and Records Control A management function in which standards and guidelines are developed for the development, maintenance, and handling of forms and records. Records Control,Forms Control,Records Management,Controls, Records,Management, Records,Records Controls
D006779 Hospitals, Public Hospitals controlled by various types of government, i.e., city, county, district, state or federal. Public Hospitals,Hospital, Public,Public Hospital

Related Publications

M Pérez-Cebrián, and I Font-Noguera, and L Doménech-Moral, and V Bosó-Ribelles, and P Romero-Boyero, and J L Poveda-Andrés
Microcomputer-assisted monitoring of medication-dispensing errors.
September 1989, American journal of hospital pharmacy,
M Pérez-Cebrián, and I Font-Noguera, and L Doménech-Moral, and V Bosó-Ribelles, and P Romero-Boyero, and J L Poveda-Andrés
Medication administration errors in nursing homes using an automated medication dispensing system.
January 2009, Journal of the American Medical Informatics Association : JAMIA,
M Pérez-Cebrián, and I Font-Noguera, and L Doménech-Moral, and V Bosó-Ribelles, and P Romero-Boyero, and J L Poveda-Andrés
Medication errors: the importance of safe dispensing.
June 2009, British journal of clinical pharmacology,
M Pérez-Cebrián, and I Font-Noguera, and L Doménech-Moral, and V Bosó-Ribelles, and P Romero-Boyero, and J L Poveda-Andrés
Automated drug dispensing system reduces medication errors in an intensive care setting.
December 2010, Critical care medicine,
M Pérez-Cebrián, and I Font-Noguera, and L Doménech-Moral, and V Bosó-Ribelles, and P Romero-Boyero, and J L Poveda-Andrés
Medication errors in hospitals: computerized unit dose drug dispensing system versus ward stock distribution system.
June 2003, Pharmacy world & science : PWS,
M Pérez-Cebrián, and I Font-Noguera, and L Doménech-Moral, and V Bosó-Ribelles, and P Romero-Boyero, and J L Poveda-Andrés
Occurrence of dispensing errors and efforts to reduce medication errors at the Central Arkansas Veteran's Healthcare System.
January 2004, Drug safety,
M Pérez-Cebrián, and I Font-Noguera, and L Doménech-Moral, and V Bosó-Ribelles, and P Romero-Boyero, and J L Poveda-Andrés
Interplay of medication errors and the separation of dispensing.
January 2016, Research in social & administrative pharmacy : RSAP,
M Pérez-Cebrián, and I Font-Noguera, and L Doménech-Moral, and V Bosó-Ribelles, and P Romero-Boyero, and J L Poveda-Andrés
[Medication dispensing errors detected in medication cassettes intended for in-hospital patients].
September 2008, Journal de pharmacie de Belgique,
M Pérez-Cebrián, and I Font-Noguera, and L Doménech-Moral, and V Bosó-Ribelles, and P Romero-Boyero, and J L Poveda-Andrés
Medication dispensing errors at a public pediatric hospital.
January 2008, Revista latino-americana de enfermagem,
M Pérez-Cebrián, and I Font-Noguera, and L Doménech-Moral, and V Bosó-Ribelles, and P Romero-Boyero, and J L Poveda-Andrés
Medication dispensing errors in a French military hospital pharmacy.
August 2009, Pharmacy world & science : PWS,
Copied contents to your clipboard!