The Frequency and Potential Causes of Dispensing Errors in a Hospital Pharmacy

Beso, Adrian; Franklin, Bryony Dean; Barber, Nick

doi:10.1007/s11096-004-2270-8

Cited by 149 publications

(229 citation statements)

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“…There are different methods to evaluate dispensing errors, which makes it difficult to compare results between different studies (14) . In the study sample, the total error rate was considered high when compared with other studies using a similar method (4)(5)10) . The causes of errors presented in this study can be of several origins, which require a deeper evaluation with qualitative studies, though some critical points can be raised as possible…”

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“…These errors also represent an important economic cost and measures to reduce and prevent them are necessary (2,10) . Discovering their frequency and defining ways to prevent them is an important strategy to reduce risks, especially in special populations like children.…”

Section: Introductionmentioning

confidence: 99%

“…

The rate of errors is considered one of the best indicators of quality of medication distribution systems and is still used to evaluate the safety of these systems (4,6,9) .

Some studies, published in the United States and England, showed an incidence of dispensing errors of about 10%, even in hospitals with advanced medication distribution systems, such as unit doses (7,11) .

A few studies were carried out in Brazil, specifically on medication dispensing processes, and presented high rates of errors, above 10% (5,8) .

…”

mentioning

confidence: 99%

“…Literature suggests that the incidence of medication errors in pediatrics is twice or three times as high as in adults, and also that pediatric patients are at higher risk of death when compared to adults (7)(8)(9)(10)(11) . These errors also represent an important The pharmacy service is responsible for the safe and efficient use of medication in hospitals and plays an essential role in integrating the prescription, dispensing and administration processes and should have policies and procedures to prevent errors (4)(5)8) .…”

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Medication dispensing errors at a public pediatric hospital

Costa

Valli

Alvarenga³

2008

Rev. Latino-Am. Enfermagem

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(4)(5)(6) .Literature suggests that the incidence of medication errors in pediatrics is twice or three times as high as in adults, and also that pediatric patients are at higher risk of death when compared to adults (7)(8)(9)(10)(11) . These errors also represent an important The pharmacy service is responsible for the safe and efficient use of medication in hospitals and plays an essential role in integrating the prescription, dispensing and administration processes and should have policies and procedures to prevent errors (4)(5)8) .The rate of errors is considered one of the best indicators of quality of medication distribution systems and is still used to evaluate the safety of these systems (4,6,9) .Some studies, published in the United States and England, showed an incidence of dispensing errors of about 10%, even in hospitals with advanced medication distribution systems, such as unit doses (7,11) .A few studies were carried out in Brazil, specifically on medication dispensing processes, and presented high rates of errors, above 10% (5,8) . In the pediatric area, especially in Brazil, no study was found on dispensing errors and, to date, their cause and epidemiology are unknown.Therefore, this study aims to evaluate the dispensing process of the pharmacy service at a public pediatric hospital. Important indicators were used to measure the dispensing process and the rate of total dispensing errors was the global indicator of its quality. MATERIAL AND METHODS Study designCross-sectional, descriptive study, carried out Variables OperationalizationErrors were classified according to the criteria used in a previous study (10) in:Content errors

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“…

The rate of errors is considered one of the best indicators of quality of medication distribution systems and is still used to evaluate the safety of these systems (4,6,9) .

A few studies were carried out in Brazil, specifically on medication dispensing processes, and presented high rates of errors, above 10% (5,8) .

…”

mentioning

confidence: 99%

mentioning

confidence: 99%

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Medication dispensing errors at a public pediatric hospital

Costa

Valli

Alvarenga³

2008

Rev. Latino-Am. Enfermagem

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The impact of an integrated electronic medication prescribing and dispensing system on prescribing and dispensing errors: a before and after study

Hodgkinson

Larmour

Lin

et al. 2017

Pharmacy Practice and Res

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Background Medication errors are a significant problem in Australian hospitals. This is the first study of the impact of an integrated electronic medication prescribing (e‐prescribing) and dispensing system on medication errors. Aim To evaluate the impact of an integrated e‐prescribing and dispensing system implemented in outpatient clinics and the emergency department on prescribing and dispensing errors. Method Prescribing and dispensing errors were identified over 2 weeks before and after implementation of the integrated system. Errors were identified through original prescription, e‐prescribing and dispensing systems review. Error rates, types, severity and patient waiting times for prescription dispensing were compared. Results The study included 379 patients prescribed 654 medicines in the before group and 375 patients prescribed 635 medicines in the after group. Prescribing and dispensing error rates per patient were reduced by 93% (from 2.98 to 0.2; p < 0.0001) and 98% (from 1.27 to 0.03; p < 0.0001), respectively. The proportions of patients with at least one procedural or clinical prescribing error showed significant reductions of 81% (95% CI 77–85%) and 3.4% (95% CI 0.1–6.7%). The proportions of patients with at least one procedural or clinical dispensing error showed signicant reductions of 61% (94% CI 56–66%) and 2% (95% CI 0.7–3.6%). Fifty system‐related prescribing errors were identified. Mean error severity score was minor in both groups. Median patient waiting time for prescription dispensing was reduced by 52% (from 27 to 13 min; p < 0.0001). Conclusion Implementation of the integrated system significantly reduced prescribing and dispensing errors and patient waiting times for prescription dispensing. Clinicians need to manage new system‐related errors to reduce associated risks.

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Implementation of robotics in the Australian hospital pharmacy dispensary: adding to the evidence

Vekaria

Boardman

Tam

et al. 2021

Pharmacy Practice and Res

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Dear Editor,We congratulate Hogan et al. 1 on the recent publication of their article assessing the impact of implementing a pharmacy robotics dispensing system (PRDS) on dispensing and imprest supply in an Australian tertiary hospital pharmacy. Until now, there has been no local data examining the use of PRDS. We add our findings regarding PRDS implementation on the dispensing process in the Australian hospital pharmacy setting.Fiona Stanley Hospital, a new quaternary referral hospital, implemented PRDS in the pharmacy dispensary and stores areas. We compared the efficiency and accuracy of a manual dispensing process against the PRDS dispensing process following the installation of pharmacy robotics. The robot (Roma Vmax â ; Becton Dickinson, Franklin Lakes, New Jersey, USA) is a whole pack chaotic storage device with dual multi-pick robotic heads, equipped with both fully and semi-automated inputting devices, conveyor chutes and a stock crating system, and has bidirectional interface with iPharmacy, the medication dispensing and stock management system.The dispensing stages assessed were: typing the label, picking stock, labelling and final check. We implemented a hybrid workflow with the use of both robotic and manual processes when picking stock. The manual picking process was for items that were unable to be stored in the robot such as refrigerated items and part packs.One study author (SV) directly observed dispensing activity, recording timing and errors for each stage of dispensing.After PRDS was implemented, each item required a mean of 13 s longer to dispense (see Table 1). The labelling stage increased with PRDS while typing and checking times were unchanged. The potential causes of this included: lack of familiarity with the PRDS process and the presence of less experienced dispensary support staff responsible for the labelling step. As expected, PRDS led to a decrease in picking time. Prescription urgency and workload were not assessed. Hogan et al. 1 suggest that PRDS efficiency benefits explain their unchanged overall prescription turnaround times and staff productivity despite an increased dispensary workload. Other published research assessing the time impact post-PRDS implementation is conflicting. 2 *Significance of picking method in a regression equation including picking method and number of items as independent variables and stage time as dependant variable

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The Frequency and Potential Causes of Dispensing Errors in a Hospital Pharmacy

Abstract: Dispensing errors occur in about 2% of all dispensed items. About 1 in 100 of these is missed by the final check. The impact on dispensing errors of developments such as automated dispensing systems should be evaluated.

Cited by 149 publications

References 22 publications

Medication dispensing errors at a public pediatric hospital

Medication dispensing errors at a public pediatric hospital

The impact of an integrated electronic medication prescribing and dispensing system on prescribing and dispensing errors: a before and after study

Implementation of robotics in the Australian hospital pharmacy dispensary: adding to the evidence

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