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Objective To understand the current situation of dispensing errors and effective prevention and control measures in outpatient pharmacies in domestic hospitals, in order to further improve the quality of drug dispensing. Methods The Chinese journal database was retrieved from 2015 to 2020 for the literature on the dispensing errors of outpatient pharmacies and the continuous improvement of the quality after the measures were taken in secondary and tertiary hospitals. Results Of the 146 literatures retrieved, 13 were included in the analysis (11 in tertiary hospitals and 2 in secondary hospitals). Before the improvement, the median of the drug dispensing error rate was 5.1‰, and after the improvement it was 1.1‰. Before and after the improvement, the types of drug dispensing errors were mainly quantity errors (52.5% vs. 51.3%), variety errors (28.3% vs. 28.7%), specifications and dosage forms errors (6.2% vs. 6.7%), and labeling errors (2.1% vs. 2.9%). The improvement measures taken for the reasons of dispensing errors have a high overlap rate, and they are concentrated in two aspects: personnel factors and drug factors. Conclusion The use of continuous quality improvement tools in hospital outpatient pharmacy to control and prevent dispensing errors is still a hotspot of current research. The composition of the types of errors after improvement has basically not changed. The implemen-tation of standardized operating procedures and other continuous improvement comprehensive measures can effectively reduce the incidence of dispensing errors, and contribute to the implementation of the “Expert Consensus on Medication Error Management in China”.
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Objetivo: identificar tipos de erros na dispensação de medicamentos (ED), analisar fatores associados e propor medidaspara prevenção de acidentes. Método: estudo transversal realizado com 5.604 medicamentos dispensados em hospital universitário brasileiro, em 2016/2017. Após obtenção dos dados, pela aplicação de checklist e abertura dos kits de dispensação, utilizou-se regressão hierarquizada ajustada para identificação dos fatores associados ao ED. Resultados: os ED ocorreram em 236 medicamentos e os métodos de cálculo mostraram as taxas: 4,2%, 7,3% e 24,9%. Os principais erros foram de conteúdo por desvio de qualidade e de omissão. No modelo final da regressão, permaneceram associadas ao aumento da chance de ED as variáveis: turno da noite e presença de fonte de interrupção/distração. Conclusão: a frequência de ED foi mais baixa quando se utilizou o método de cálculo do Ministério da Saúde. Os fatores relacionados ao turno noturno e ao uso de fontes de interrupção/distração podem estar associados a ED, especialmente a omissão.
Objective: to identify types of medication dispensing (DE) errors, to analyze its associated factors and to propose action for preventing accidents. Method: a cross-sectional study was performed with 5,604 drugs dispensed in a Brazilian teaching hospital, in 2016/2017. After data collection, by applying a checklist and opening dispensing kits, adjusted hierarchical regression was applied to identify factors associated with DE. Results: DE occurred in 236 medications and calculation methods led to the rates: 4.2%, 7.3%. and 24.9%. The main dispensing errors were related to content, due to quality deviation, and omission. In the final regression model, the following variables remained associated with an increased chance of DE: overnight shift and the presence of interruption/distraction sources. Conclusion: the frequency of DE was low when using the calculation method of the Brazilian Ministry of Health. Factors related to the night shift and the use of interruption/distraction sources can be associated with DE, especially those related to omission.
Objetivo: identificar los tipos de errores en la dispensación de medicamentos (ED), analizar los factores asociados y proponer medidas de prevención de accidentes. Método: estudio transversal realizado con 5,604 medicamentos dispensados en un hospital universitario brasileño, en 2016/2017. Después de obtidos los datos, aplicando un checklist y abriendo los kits de dispensación, se utilizó la regresión jerárquica ajustada para identificar los factores asociados con la DE. Resultados: ocurrió ED en 236 medicamentos y los métodos de cálculo mostraron las tasas: 4.2%, 7.3% y 24.9%. Los principales errores fueron de contenido debido a la desviación de calidad y la omisión. En el modelo de regresión final, las variables: turno nocturno y presencia de fuentes de interrupción/distracción permanecieron asociadas con mayor probabilidad de ED. Conclusión: la frecuencia de DE fue menor cuando se utilizó el método de cálculo del Ministerio de Salud. Los factores relacionados con el turno nocturno y el uso de fuentes de interrupción/distracción pueden estar asociados con DE, especialmente la omisión.
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Humans , Male , Female , Drug Dispensaries , Patient Safety , Medication Errors , Medication Errors/adverse effects , Medication Errors/prevention & control , Medication Systems , Cross-Sectional StudiesABSTRACT
OBJECTIVE:To improve dispensing quality of small package of TCM formula granule, reduce the rate of dispensing error and shorten dispensing time. METHODS:Key influential factors for small package of TCM formula granule dispensing in our hospital were found out from 5 respects of"man,machine,environment,method,material";two cycles of PDCA cycle management intervention were conducted. Dispensing internal error and dispensing time were compared before PDCA cycle management intervention (Jul.-Dec. 2015,group A),first cycle of PDCA cycle management intervention (Jan.-Jun. 2016, group B) and second cycle of PDCA cycle management intervention (Jul.-Dec. 2016,group C),the effects of management were evaluated. RESULTS:By improving dispensing environment,establishing dispensing standard operation procedure,formulating reward and punishment system,staff training,after 2 cycles of PDCA cycle management intervention,the rate of small package of TCM formula granule dispensing error in TCM pharmacy of our hospital decreased from 4.19％(170/4061) before intervention that of group A to 1.69％(85/5043) and 0.98％(53/5408) in group B and C after intervention (P<0.05 or P<0.01). Average dispensing time of each prescription with 7 doses were shortened from(9.08±2.56)min before intervention(group A)to(7.37± 1.98),(5.97±1.64)min in group B and C after intervention(P<0.05). CONCLUSIONS:PDCA cycle management intervention in our hospital can reduce the rate of small package of TCM formula granule dispensing error and shorten dispensing time.
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OBJECTIVE:To promote the informatization of adverse drug event(ADE)management in outpatient pharmacy so as to reduce the risk of drug use. METHODS:From the aspect of the construction of two information platforms as problematic prescription management and ADR monitoring record and report,the practice of the informatization of ADE management in outpatient pharmacy of our hospital was introduced;the effects of information management were evaluated by real-time online record for the number of dispensing error and ADE and the number of ADR reported by outpatient pharmacists. RESULTS:The application of ADE management module for outpatient pharmacy developed by our hospital realized the following functions as real-time online record of"suspected prescription",problematic prescription inquiry and summary,ADE report without delay, electronic ADR monitoring and reporting. 148 times of dispensing internal errors during Apr.-Jun. 2017(accounting for 0.035% of total prescription)and 15 ADEs during Jun. 2016-Jun. 2017(accounting for 0.008‰ of total prescription)were recorded in outpatient pharmacy of our hospital. There were 82 ADR cases reported by outpatient physicians using user-friendly electronic ADR monitoring and reporting(accounting for 36.94% of total ADR). CONCLUSIONS:The construction of informatization promotes timely record of related error and adverse events,targeted management and ADR reporting and reduces the risk of drug use.
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OBJECTIVE; To improve the PIVAS quality management, reduce dispensing error and promote the safety of drug use.METHODS: The quality control circle (QCC) was used for quality management in PIVAS of our hospital. The reasons for dispensing errors were analyzed to determine the key improvement points using "the reduction of dispensing error of admixture drugs" as theme. Improvement plan was formulated, and effective countermeasures were determined by PDCA (Plan, Do, Check, Action) cycle management. The tangible results (the rate of dispensing errors) and intangible results were compared before (Feb. 2016) and after QCC (Aug. 2016). RESULTS: Some effective measures were formulated and implemented, including unified arrangement, introducing PIVAS MATE process management software, personnel post training, refining drug withdrawal management, visual management, etc. The tangible results included the rate of dispensing error decreased from 1. 81‰ to 0. 53‰; the rate of goal achievement reached 108. 47％; the rate of target progress was 70. 72％. The intangible results included optimizing drug dispensing process, standardizing drug withdrawal systent and personal training system. Those achievement improved confidence, responsibility, sense of cooperation and cohesiveness of QCC members. Additional result was obtained, i. e. utility model patent for avoiding light storage box. CONCLUSIONS: QCC can effectively improve the management quality of PIVAS workflow and the safety of intravenous medication.
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OBJECTIVE:To refine the quality standard of pharmacy intravenous admixture service(PIVAS),and provide refer-ence for improving the work quality of PIVAS. METHODS:Through establishing quality management organization and developing quality standard rules,quality control system for PIVAS in our hospital was constructed and total quality management was conduct-ed. Numbers of quality problems before(Jul. 2013-Jun. 2014)and after(Jul. 2014-Jun. 2015)its implementation were compared, and the effects were evaluated. RESULTS:117 management systems and 14 link quality standards and rules were made,including staff behavior standards,quality standards for drug management,supervision and inspection of quality standards,etc. Numbers of quality problems dropped from 358 to 177 after the implementation,the ratio of dispensing errors accounted for the total dispensing declined from 0.35? to 0.17?(P<0.05). CONCLUSIONS:The construction of quality control system and the implementation of quality control standards and rules in PIVAS of our hospital has improved the quality of PIVAS work.
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<b>Objective: </b>Similarity in drug appearance is one of the major environmental factors influencing dispensing errors, such as picking the wrong medication (picking error). The purpose of this study is to verify if the index values of appearance similarity calculated objectively for multiple-specification drugs are the factors of picking error.<br><b>Methods: </b>Four variables (number of total prescription, deviation of prescriptions between the specifications, sheet size, and color similarity of the sheet surface) were calculated. The number of total prescription and deviation of prescriptions were extracted from the dispensing system. Sheet size and color similarity were calculated, respectively, from the area ratio and by the Histogram Intersection method using the press through package (PTP) sheet image. To evaluate the relationship between the picking error rate and these four variables, univariate and multivariate analyses were performed.<br><b>Results: </b>The number of total prescription and the deviation of prescriptions were not significant factors. In contrast, sheet size and color similarity significantly influenced the picking error rates.<br><b>Conclusion: </b>Similarity in appearance between multiple-specification drugs is a risk factor of picking error. When the multiple-specification pair has the same sheet size or high color similarity, one needs to be caution of picking error. Further, in the pharmaceutical industry, to reduce the risk of dispensing errors, it is desirable to carry out the devise to enhance the identity of each specification.
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Objective:To provide reference for the introduction and application of intelligent access system. Methods:The intelli-gent access system and its work process in our hospital were introduced. The application effects in the emergency pharmacy were inves-tigated and the key points that should be paid more attention in the practice were discussed. Results:Comparing with the situation be-fore the application, the system could decrease prescription time by about 26. 1% and reduce walking work intensity by about 5 times, and the drug store room was decreased by about 30%. No dispensing error happened in nearly half a year after the application of the in-telligent access system. Conclusion:The application of intelligent access system in emergency pharmacy is the development trend of the future.
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<b>Objective: </b>Taking the wrong medicine or medication error is a serious concern to patient safety. The aim of this study was to statistically survey the relation between the placement of drugs on medicine shelf and the occurrence of error in taking a medicine.<br><b>Methods: </b>The study comprised 2 groups. The incident group contained 43 cases that were erroneously taken in the Obihiro Kosei General Hospital. The control group contained 43 drug pairs matched by the similarity index of the drug names from among the drugs used in the hospital at random. The similarity index of drug names was based on 10 quantitative indicators. The distance of medicine shelf arrangement was represented by three variables: the horizontal distance, the vertical distance and the distance of shelf block. Conditional logistic regression analyses of the occurrence of medication errors were performed by evaluating the three variables of the distance factor and their interaction for error in taking a similar-sounding named drugs.<br><b>Results: </b>Conditional logistic regression analysis revealed that the vertical distance (OR: 0.64, 95%CI: 0.42-0.99) and the distance of the shelf block (OR: 0.74, 95%CI: 0.57-0.97) were significant risk-reduction factors of medication errors. Four variables were extracted as the most suitable logistic regression model in terms of the interaction between them. As the interaction between 3 variables (the horizontal distance, the vertical distance and the distance of shelf block) was significant (OR: 0.93, 95%CI: 0.86-0.99), they may be considered as synergistic risk-reduction factors. Moreover, the horizontal distance was found to be a risk-enhancement factor (OR: 1.52, 95%CI: 0.93-2.48).<br><b>Discussion: </b>In order to reduce the risk of medication errors due to similar-sounding drug names, placement of drug on the medicine shelf should take into consideration the three coordinates of the distance factor.
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<b>Objective: </b>Similarity of drug names is one factor of dispensing incidents. The aim of this study was to survey the relation between sensual similarities of drug names and the occurrence of taking errors for pharmacists who actually prepare medicine.<br><b>Methods: </b>A pair of drugs (15 incident pairs and 104 control pairs) was displayed on a computer screen at random. The subject’s task was to determine the sensual similarity of them. Thirteen pharmacists who prepared these pairs and caused their incidents participated in the experiment.<br><b>Results: </b>The result showed that the sensual similarity of drug names of incident pairs was found to be highly significant in comparison to one of the control pairs [<i>p</i>=0.026]. However, the similarity in incident pairs is not necessarily high. It was suggested that the similarity of drug name was not the only factor of taking error. Multiple linear regression analyses of the sensual similarity in control pairs were performed, in which 10 variables were reported as quantitative indicators of similarity of drug name and were able to be measured on the internet. The correlation was good [<i>R</i><sup>2</sup>=0.828]. However, this regression model was not useful when adjusting to incident pairs. In incident pairs, the similarity value calculated by the regression model was lower than the measured sensual similarity.<br><b>Conclusion: </b>The result suggested that measured sensual similarity includes other risk factors of taking error, such as appearance similarity and/or efficacy similarity and/or short distance arrangement. It seemed that the pharmacist’s ability complicated the factor of taking error.
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OBJECTIVE:To improve hospital dispensing system and reduce dispensing error. METHODS: The causes of 65 cases of dispensing error occurred in outpatient pharmacy were analyzed by employing total quality management (TQM) method from 5 aspects: human,machine,material,method and environment. RESULTS: Among the 5 kinds of factors,the "human" factor took the lead,which accounted for 83% of the dispensing errors. Quality control carried out aimed at the primary factor contributed to the reduction of dispensing error cases,down from previous annual average 16 cases to 1 case of the first 10 month in 2008. CONCLUSION: TQM method contributed to the reduction of dispensing error rate in hospital outpatient pharmacy.
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OBJECTIVE: To provide reference for the reduction of dispensing error rate and the hidden dispensing danger in outpatient pharmacy.METHODS: The drugs with similar outer package in the outpatient pharmacy of a hospital in 2007 were investigated and knew the hidden drug dispensing danger caused by similar outer package by the staff mambers in the outpatient pharmacy.RESULTS: A total of 7 pairs of drugs were found to be of similar outer package in pattern,color or the size of package etc,which resulted in hidden dispensing errors in 39 cases.CONCLUSIONS: Great importance should be attached to the drugs with similar outer packages and countermeasures should be taken to avoid the hidden dispensing errors induced by it.
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OBJECTIVE: To exchange the working experiences in community pharmacy so as to avoid dispensing error. METHODS: The causes of dispensing error in computerized community pharmacy and the related countermeasures were discussed. RESULTS: To prevent dispnesing error in the computerized community pharmacy, it is urgernt for the concerned personnel to improve their professional level and working ability and arrange drugs scientifically. CONCLUSION: Great importance should be attached to the dispensing error in community pharmacy to provide patients with a high quality community health service.