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Drug-dispensing errors in the hospital pharmacy
Tânia Azevedo Anacleto1, Edson Perini, Mário Borges Rosa
1Hospital João XXIII, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil. taniaanacleto@yahoo.com
Clinics (Sao Paulo, Brazil)
|June 26, 2007
Summary
Hospital pharmacies experience high dispensing error rates, with over 81% of prescriptions containing errors. Factors like pre-typed forms and complex medication orders increase the risk, indicating systemic issues in dispensing processes.
Area of Science:
- Pharmacy Practice
- Patient Safety
- Healthcare Systems Analysis
Background:
- Dispensing errors in hospitals pose significant risks to patient safety.
- Understanding the contributing factors is crucial for implementing effective error prevention strategies.
Purpose of the Study:
- To quantify the dispensing error rate within a general hospital pharmacy.
- To identify specific factors associated with dispensing errors.
- To inform the development of targeted prevention actions.
Main Methods:
- A cross-sectional study was conducted in a general hospital pharmacy in Belo Horizonte.
- The study analyzed 422 prescription order forms within a mixed dosing system (multidose and unit dose).
- Statistical analysis, including multivariate analysis, was used to identify risk factors.
Main Results:
- A high dispensing error rate of 81.8% was observed, with at least one error per prescription.
- Prescription order forms that were pre-typed (OR=4.5), contained 9 or more drugs (OR=4.0), or were for injectable drugs (OR=5.0) showed significantly higher error rates.
- One professional team exhibited a higher likelihood of errors (OR=2.0).
Conclusions:
- The hospital's dispensing system contains numerous latent failures and lacks adequate control mechanisms.
- The current system's conditions predispose it to a high incidence of dispensing errors.
- Systemic improvements are necessary to reduce medication errors and enhance patient safety.
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