Errores de medicación en un hospital terciario con tres sistemas de distribución de medicamentos diferentes

Abstract

In one of each 14 opportunities for error a medication error takes place. The different delivery medication systems have different error rates.

Intervention study for the reduction of medication errors in elderly trauma patients

“…These authors found a prevalence of VEs of 0.1%, which is similar to the results of both phases of the present study (ie, 0.3% and 0.1%, respectively) 29 . Other authors have found prevalences of between 2.0% and 27.0%: however, some studies have found that VEs comprise 10.0% of all MEs 30 . It is difficult to compare the prevalence of VEs, depending on the methodology, associate the validation and transcription errors, or those of prescription and validation.…”

“…In the pre‐implementation phase, the most frequent type of DE was “omission of medication,” whereas in the post‐implementation phase it was “Others: a medication that is not prescribed appears in the box.” The literature suggests that the three most frequent types of DE are “omission,” “different amount of medicines in the dispensing box” and “different dosage of the medicinal product.” 30,31 …”

New technologies applied to the medication-dispensing process, error analysis and contributing factors

“…Although we did not measure administrative errors, according to Climent et al, the omission of a dose or a medication can occur with a frequency of 20.4% and 13.4%, respectively, so we believe that measures have to be taken to improve this dispensing system. 14 In our case, the shortage or breakage of stock were the fundamental contributing factors. In this respect, it is necessary to point out that 4 months before beginning the study the use of the Kardex ® horizontal had been implemented in the hospital so the process of adjusting the maximum and minimum stocks was still in progress and this may have contributed to the high levels of stock shortage and breakage.…”

“…However, the high efficiency of the data collection method compensates for this bias, as Climent et al 14 mention in their study.…”

“…Climent et al make a global estimation for medication distribution systems of the types of errors and medication involved, analysing the factors associated with them. 14 Other authors have also analysed dispensing errors and their causes. 6,10,11,[15][16][17] In turn, Rickrode et al 18 carried out a study through an internal communication system in the PS to obtain information about any event that could have the potential to cause an error, such as errors of execution or planning, in order to be able to take measures to correct these potential problems.…”