Evaluating dispensing error detection rates in a hospital pharmacy

Area of Science:

• Pharmacy practice
• Patient safety
• Medication error detection

Background:

• Hospital pharmacies rely on accurate unit dose order fulfillment and error checking.
• Previous research suggested non-pharmacists could perform these distributive tasks.
• This study specifically evaluated licensed practical nurses (LPNs) against pharmacists.

Purpose of the Study:

• To compare the error detection competence of pharmacists and LPNs in checking unit dose cassettes.
• To determine if LPNs match the error detection accuracy of pharmacists.

Main Methods:

• A university teaching hospital implemented a 4-month study introducing 812 artificial errors.
• Seven staff pharmacists and nine LPNs participated in the decentralized drug distribution system.
• The primary metric was the ratio of detected errors to introduced artificial errors.

Main Results:

• Pharmacists demonstrated significantly higher overall error detection accuracy (87.7%) compared to LPNs (82.1%).
• The accuracy gap widened for serious errors, particularly wrong strength medications (93.3% for pharmacists vs. 83.3% for LPNs).

Conclusions:

• Study findings do not support prior conclusions that non-pharmacists achieve equal error detection accuracy to pharmacists.
• Emphasizes the need to analyze specific error types and employ suitable metrics when evaluating checker competence.