Medication dispensing errors at a public pediatric hospital

Costa, Lindemberg Assunção; Valli, Cleidenete Gomes; Alvarenga, Angra Pimentel

doi:10.1590/s0104-11692008000500003

Cited by 21 publications

(18 citation statements)

References 9 publications

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“…The most commonly reported dispensing error was dispensing wrong drug. Previous studies have reported dispensing wrong drugs in all types of inpatient settings [25,[32][33][34][35]. Omission due to drug unavailability was also a common error identified.…”

Section: Discussionmentioning

confidence: 92%

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Drug-related problems and their clinical interventions in a Ghanaian teaching hospital

2016

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Background: Errors occur frequently in the use of medicines. Pharmacists play a key role in error identification and make appropriate interventions as they work with other healthcare professionals. These error recovery roles of pharmacists contribute to patient safety. This study was to evaluate the clinical interventions made to drug-related problems at a tertiary care setting. Method: This involved a retrospective review of clinical intervention reports submitted by pharmacists working over the period January 2011 to December 2013. Results: The 24 pharmacists submitted 529 handwritten reports; of these, 448 reports had complete data. The most frequently reported drugs with error were warfarin (9.5%), potassium chloride (6.0%) and potassium citrate (5.5%). The pharmacists made 1019 clinical interventions and recommendations. The average intervention per report was 2.5 (S.D ± 0.67). The interventions and recommendations made were categorised as drug regimen change (76.1%), monitoring required (13.0%), communication (5.4%), counselling required (5.0%) and adverse drug reporting (0.6%). Majority (90.5%) of the recommendations and interventions made by pharmacists were accepted and implemented. Monitoring-required based interventions were significantly more likely to be accepted (130 vs 38; p <0.0001). Conclusion: Pharmacists played a role in drug error recovery and prevented medication errors from reaching patients. These error mitigation efforts of pharmacists can serve as a priority in patient safety strategy.

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Section: Discussionmentioning

confidence: 92%

“…The drug errors assessed in this study were reports from only pharmacists although physicians [11,21], nurses [22,23] and others [24,25] had reported drug errors in other studies.…”

Section: Discussionmentioning

confidence: 99%

Drug-related problems and their clinical interventions in a Ghanaian teaching hospital

2016

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“…Table 2 shows the rates of dispensing errors and different subtypes of dispensing errors [2–4, 6, 7, 10–16, Dutch Association of Hospital Pharmacists (NVZA): unpublished data]. The rates of dispensing errors were 0–45%.…”

Section: Recent Studies Of Dispensing Errorsmentioning

confidence: 99%

Medication errors: the importance of safe dispensing

Cheung

Bouvy

Smet

2009

Brit J Clinical Pharma

105

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1. Although rates of dispensing errors are generally low, further improvements in pharmacy distribution systems are still important because pharmacies dispense such high volumes of medications that even a low error rate can translate into a large number of errors. 2. From the perspective of pharmacy organization and quality assurance, pharmacists should intensify their checking of prescriptions, in order to reduce prescription errors, and should implement strategies to communicate adequately with patients, in order to prevent administration errors. More and better studies are still needed in these areas. 3. More research is also required into: dispensing errors in out-patient health-care settings, such as community pharmacies in the USA and Europe; dispensing errors in hospitals and out-patient health-care settings in middle-and low-income countries; and the underlying causes of dispensing errors.Six main types of medication error can occur in the chain of pharmacological and pharmaceutical patient care: prescribing faults, prescription errors, transcription errors, dispensing errors, administration errors, and 'across settings' errors [1]. In this article we focus on dispensing errors. Definition of a dispensing errorA dispensing error is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient or distributes to the ward on the basis of this prescription, including the dispensing of a medicine with inferior pharmaceutical or informational quality [1-6]. Table 1 shows the categories of dispensing errors [1,2,3,6,7]. If dispensing errors are considered from the perspective that the quality of all pharmacy care activities should be assured by the pharmacist, this list can be extended by the addition of three other categories: failure to detect and correct a prescribing error before dispensing; failure to detect a manufacturing error before dispensing; and failure to provide adequate patient counselling in order to prevent administration errors. These categories arise in other segments of the pharmaceutical patient care chain, but they are nevertheless important when one strives for a full assessment of the pharmacy's performance [8,9]. Categories of dispensing error Recent studies of dispensing errorsWe searched Pubmed on-line using the keywords 'dispensing errors' and related search terms. We also searched manually for related articles in the reference lists of the studies we retrieved and selected. We used only studies that were published in English after 2003. Table 2 shows the rates of dispensing errors and different subtypes of dispensing errors [2-4, 6, 7, 10-16, Dutch Association of Hospital Pharmacists (NVZA): unpublished data]. The rates of dispensing errors were 0-45%. The highest rates of dispensing errors were in studies in which a researcher observed the dispensing process or checked and compared the dispensed medicines against the relevant prescriptions. Some studies used a self-reporting system to count the number of dispensing errors. These studies did not pro...

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“…This is a current issue that has been widely discussed in scientific papers (13)(14)(15) should be designed with accuracy and responsibility (16)(17) . In this study, the information obtained from qualified professionals that make up the Brazilian Network of Sentinel Hospitals/ANVISA contributed to value this condition.…”

Section: Discussionmentioning

confidence: 99%

Risk Management in Technovigilance: construction and Validation of a Medical-Hospital Product Evaluation Instrument

Kuwabara¹,

Évora

Oliveira

2010

Rev. Latino-Am. Enfermagem

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With the continuous incorporation of health technologies, hospital risk management should be implemented to systemize the monitoring of adverse effects, performing actions to control and eliminate their damage. As part of these actions, Technovigilance is active in the procedures of acquisition, use and quality control of health products and equipment.This study aimed to construct and validate an instrument to evaluate medical-hospital products. This is a quantitative, exploratory, longitudinal and methodological development study, based on the Six Sigma quality management model, which has as its principle basis the component stages of the DMAIC Cycle. For data collection and content validation, the Delphi technique was used with professionals from the Brazilian Sentinel Hospital Network.It was concluded that the instrument developed permitted the evaluation of the product, differentiating between the results of the tested brands, in line with the initial study goal of qualifying the evaluations performed. Administración de riesgo en tecnovigilancia: construcción y validación de un instrumento de evaluación de producto Médico hospitalarioCon la continua incorporación de tecnologías en la salud, la administración de riesgo hospitalario debe ser implantada para sistematizar la monitorización de eventos adversos, ejecutando acciones para el control y eliminación de sus daños. Como parte de esas acciones, la Tecnovigilancia actúa en los procedimientos de adquisición, utilización y control de calidad de productos y equipamientos en el área de la salud. El objetivo de este estudio fue construir y validar un instrumento de evaluación de productos Médico hospitalarios. Se trata de un estudio cuantitativo, exploratorio, longitudinal y de desarrollo metodológico, fundamentado en el modelo de gestión de calidad Seis Sigma, que tiene como base principal las etapas componentes del Ciclo DMAIC. Para la obtención de datos y la validación de contenido, se utilizó la técnica Delphi con profesionales de la Red Brasileña de Hospitales Centinela. Se concluyó que el instrumento desarrollado posibilitó evaluar el producto, diferenciando los resultados entre las marcas probadas y retratando el propósito inicial del estudio de calificar las evaluaciones realizadas.

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Medication dispensing errors at a public pediatric hospital

Cited by 21 publications

References 9 publications

Drug-related problems and their clinical interventions in a Ghanaian teaching hospital

Drug-related problems and their clinical interventions in a Ghanaian teaching hospital

Medication errors: the importance of safe dispensing

Risk Management in Technovigilance: construction and Validation of a Medical-Hospital Product Evaluation Instrument

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