Prevention of Drug Dispensing Errors by Using Personal Digital Assistance and Recording the Number of Agents

Abstract

The main function of pharmaceutical care is to dispense drugs. The process of drug dispensing is getting simpler as a result of the development of automated dispensing systems, however the traditional dispensing system/process, manually selecting drugs from shelves and transferring the correct number of dose units to labeled paper bags, is complicated and still adopted in a majority of hospital pharmacies in Japan. The complicated dispensing process leads to human error. Thus, pharmacists must address and minimize human error in drug dispensing. To address human error in dispensing, we adopted a dispensing support system (Patient oriented risk management system: PORIMS) with using personal digital assistance (PDA). In this study, to evaluate efficiency PORIMS in dispensing incidents, we categorized dispensing incidents into 2 groups, prevented dispensing incidents (PreDIs) and dispensing incidents (DIs), and then investigated the number of dispensing incidents. Incidents were recorded and categorized when a pharmacist double-checked assembled products/medication. As a result, the total number of PreDIs was significantly reduced by using PORIMS, 52.4 to 39.5 /1,000 prescriptions/month (P < 0.001). Selection errors and forgetful dispensing were completely prevented. Counting errors were significantly reduced by recording the number of agents before assembly (13.85 ± 3.19 to 5.37 ± 1.15/month, P = 0.026). The use of PORIMS was associated with a decrease in the number of reports on drug dispensing errors. In this study, we clearly demonstrated that PORIMS should be useful in the prevention of human error in drug dispensing. PORIMS enhances the performance of pharmacists.Key words -dispensing error, dispensing incident, personal digital assistance, dispensing support system, recording the number of agents, safety management

Evaluating the safety and efficiency of robotic dispensing systems

“…The most case of wrong quantity in periods 2 and 3 occurred when we used Hp-PORIMS® (data not shown). These results were consistent with those of a previous study [ 6 ]. In contrast with Hp-PORIMS®, which requires manual checking of the number of medicines, Drug Station® can confirm the number of medicines using the built-in camera and/or built-in electric scale.…”

“…To date, numerous automated dispensing devices have been implemented, and safety and efficiency in the dispensing process has been achieved by implementing these devices [ 2 , 4 , 5 , 13 – 19 ]. We introduced the automated dispensing robot (Drug Station®) and the automated dispensing robot for powdered medicines (Mini DimeRo®) [ 4 ], the bar-corded dispensing support system (Hp-PORIMS®) [ 6 ]. Although the effect of the latter two devices have been reported [ 4 , 6 ], that of Drug Station® have not been reported.…”

“…We introduced the automated dispensing robot (Drug Station®) and the automated dispensing robot for powdered medicines (Mini DimeRo®) [ 4 ], the bar-corded dispensing support system (Hp-PORIMS®) [ 6 ]. Although the effect of the latter two devices have been reported [ 4 , 6 ], that of Drug Station® have not been reported. In Japan, press-through package (PTP, also known as blister pack) sheet, bottle, sachet etc.…”

“…This system control prescriptions and medicine packages by bar coding and collates using PDA whether the drug is picked correctly according to the prescription. This system considerably reduced dispensing errors [ 6 ]. This system was used for 126 oral or topical medicines, which could not be stored in the automated dispensing robot.…”

Study of Factors Affecting Medical Incident: 1. Dispensing

“…In recent years, progress has been made toward the development of a fully automated system for the purpose of medicine dispensing. In addition, dispensing support systems using mobile information terminals, and the like, have also been employed as measures to prevent dispensing errors [2]. Automating the dispensing, or having it replaced by artificial intelligence (AI) will not, however, eradicate human error.…”