Monitorización de errores de medicación en dispensación individualizada mediante el método del carro centinela / No disponible

Objetivo Analizar la eficacia de una nueva estrategia de control de calidad basada en el muestreo aleatorio y seguimiento de carros de dispensación de dosis unitaria (carro centinela) para identificar los errores en las distintas fases del proceso de dispensación y sus causas. Método Estudio prospectivo para valoración de eficacia de un control de calidad en la identificación de errores de dispensación durante un periodo de 12 meses. Una vez por semana fue aleatoriamente seleccionado un carro de medicación denominado «carro centinela» y doblemente revisado antes de la dispensación. Se registraron los errores de medicación en la revisión, antes de ser conducido a la unidad de hospitalización así como las reclamaciones tras su recepción y monitorización durante las 24h siguientes. Un grupo de calidad de dosis unitarias instaurado al efecto analizó el tipo y origen de los errores y propuso las correspondientes acciones de mejora. Resultados Se analizaron 34 carros centinela que incluyeron 5.130 líneas de medicación, y 9.952 dosis dispensadas correspondientes a 753 pacientes. Se identificaron 90 (1,8%) líneas con error de tratamiento y 142 (1,4%) dosis erróneas en la preparación en el servicio de farmacia. El error más frecuente fue la duplicidad de dosis (38%) y el fallo de memoria o atención la causa que más lo generó (69%). Cincuenta medicaciones (6,6% de pacientes) reclamadas debido principalmente al inicio de nuevos tratamientos por ingreso (52%) y 41 (0,8% del total de líneas) discrepancias respecto a la prescripción fueron registradas en el Servicio de Farmacia. En la unidad de hospitalización se registraron 37 (4,9% de pacientes) medicaciones reclamadas en su mayoría por nuevo ingreso (43,2%) y 32 (0,6% de líneas) por discrepancias con la prescripción original, cuya causa más frecuente fue fallo de memoria o falta de atención (24%). El grado de coincidencia en el registro simultáneo de incidencias por reclamaciones y demanda de nueva medicación fue del 33,3%. Además se devolvieron 433 (4,3%) dosis no administradas. Tras el análisis de calidad se generaron 64, 37 y 24 acciones de mejora dirigidas al equipo de enfermería de farmacia, farmacéuticos y Unidad de Hospitalización, respectivamente. Conclusiones: El programa del carro centinela ha demostrado su eficacia en la identificación de errores de dispensación de dosis unitarias mediante un control de calidad instaurado al principio, durante y al final del proceso, facilitando una mayor implicación de los profesionales relacionados con el mismo (AU)

Objective To assess the efficacy of a new quality control strategy based on daily randomised sampling and monitoring of a sentinel surveillance system (SSS) medication cart, in order to identify medication errors and their origin at different levels of the process. Method Prospective quality control study with one-year follow-up. An SSS medication cart was randomly selected once a week and double-checked before dispensing medication. Medication errors were recorded before the cart was taken to the relevant hospital ward. Information concerning complaints after receiving medication and 24-h monitoring was also noted. Type and origin of error data were assessed by a unit dose quality control group, which proposed relevant improvement measures. Results Thirty-four SSS carts were assessed, including 5130 medication lines and 9952 dispensed doses, corresponding to 753 patients. Ninety erroneous lines (1.8%) and 142 mistaken doses (1.4%) were identified at the pharmacy department. The most frequent error was dose duplication (38%) and its main cause was inappropriate management and forgetfulness (69%). Fifty medication complaints (6.6% of patients) were mainly due to new treatment at admission (52%), and 41 (0.8% of all medication lines), did not completely match the prescription (0.6% lines) as recorded by the pharmacy department. Thirty-seven (4.9% of patients) medication complaints due to changes at admission and 32 matching errors (0.6% medication lines) were recorded. The main cause also was inappropriate management and forgetfulness (24%). The simultaneous recording of incidences due to complaints and new medication coincided in 33.3%. In addition, 433 (4.3%) of dispensed doses were returned to the Pharmacy Department. After the Unit Dose Quality Control Group conducted their feedback analysis, 64 improvement measures for Pharmacy Department nurses, 37 for pharmacists, and 24 for the hospital ward were introduced. Conclusions: The SSS programme has proven to be useful as a quality control strategy to identify Unit Dose Distribution System errors at initial, intermediate and final stages of the process, improving the involvement of the Pharmacy Department and ward nurses (AU)

[Monitoring medication errors in personalised dispensing using the Sentinel Surveillance System method]. / Monitorización de errores de medicación en dispensación individualizada mediante el método del carro centinela.

OBJECTIVE: To assess the efficacy of a new quality control strategy based on daily randomised sampling and monitoring a Sentinel Surveillance System (SSS) medication cart, in order to identify medication errors and their origin at different levels of the process. METHOD: Prospective quality control study with one year follow-up. A SSS medication cart was randomly selected once a week and double-checked before dispensing medication. Medication errors were recorded before it was taken to the relevant hospital ward. Information concerning complaints after receiving medication and 24-hour monitoring were also noted. Type and origin error data were assessed by a Unit Dose Quality Control Group, which proposed relevant improvement measures. RESULTS: Thirty-four SSS carts were assessed, including 5130 medication lines and 9952 dispensed doses, corresponding to 753 patients. Ninety erroneous lines (1.8%) and 142 mistaken doses (1.4%) were identified at the Pharmacy Department. The most frequent error was dose duplication (38%) and its main cause inappropriate management and forgetfulness (69%). Fifty medication complaints (6.6% of patients) were mainly due to new treatment at admission (52%), and 41 (0.8% of all medication lines), did not completely match the prescription (0.6% lines) as recorded by the Pharmacy Department. Thirty-seven (4.9% of patients) medication complaints due to changes at admission and 32 matching errors (0.6% medication lines) were recorded. The main cause also was inappropriate management and forgetfulness (24%). The simultaneous recording of incidences due to complaints and new medication coincided in 33.3%. In addition, 433 (4.3%) of dispensed doses were returned to the Pharmacy Department. After the Unit Dose Quality Control Group conducted their feedback analysis, 64 improvement measures for Pharmacy Department nurses, 37 for pharmacists, and 24 for the hospital ward were introduced. CONCLUSIONS: The SSS programme has proven to be useful as a quality control strategy to identify Unit Dose Distribution System errors at initial, intermediate and final stages of the process, improving the involvement of the Pharmacy Department and ward nurses.

[Assessment of a reconciliation and information programme for heart transplant patients]. / Evaluación de un programa de conciliación e información al paciente trasplantado cardíaco.

INTRODUCTION: The objective is to assess a pharmaceutical care programme for heart transplant patients upon patient admission and discharge. MATERIAL AND METHODS: Observational study of heart transplant patients, performed during the first quarter of 2007. Upon admission, the patient was interviewed regarding home treatments, adherence, allergies and adverse effects, and his/her prescriptions were compared with the last discharge report (drug reconciliation). At time of discharge, treatment was checked against the last hospital prescription (reconciliation) and an informative report was drawn up and personally delivered to the patient. Subsequently, a satisfaction questionnaire was carried out by telephone. Drug-related problems were recorded using Atefarm software. RESULTS: The programme was applied to 24 patients upon admission and 23 upon discharge. No drug interactions were detected. Treatment adherence was higher than 90%. 37.5% of patients informed of an adverse reaction. Medication-related problems were identified in 16 patients (45.7%) for 6.6% of medications, most of which (38%) were for infection prophylaxis; medication omission was the most frequently-detected error. Positive evaluation of the information that was received was higher than 90%. CONCLUSIONS: Pharmacotherapeutic follow-up upon admission and discharge resolves and prevents problems while improving patient information and satisfaction. Limitations on personnel prevent the population's requests from being met.

Evaluación de un programa de conciliación e información al paciente trasplantado cardíaco / Assessment of a reconciliation and information programme for heart transplant patients

Introducción El objetivo es evaluar un programa de atención farmacéutica al ingreso y al alta hospitalaria del paciente trasplantado cardíaco. Material y métodos Estudio observacional realizado el primer trimestre de 2007 en pacientes trasplantados cardíacos. Al ingreso, se entrevistó al paciente sobre tratamientos domiciliarios, adherencia, alergias, efectos adversos y se comparó la prescripción con el último informe de alta (conciliación). Al alta, se comparó el tratamiento con la última prescripción hospitalaria (conciliación) y se elaboró un boletín informativo, entregándolo personalmente al paciente. Posteriormente, se realizó un cuestionario telefónico sobre satisfacción. Los problemas relacionados con los medicamentos (PRM) fueron registrados en la aplicación Atefarm®. Resultados El programa al ingreso se aplicó a 24 pacientes y al alta a 23. No se detectaron interacciones. La adherencia al tratamiento fue superior al 90%. El 37,5% de los pacientes comunicó alguna reacción adversa. Se identificaron PRM en 16 pacientes (45,7%), en un 6,6% de los medicamentos, la mayoría (38%) pertenecientes a profilaxis infecciosa, siendo la omisión del medicamento el error principalmente detectado. La valoración positiva de la información recibida superó el 90%.ConclusionesEl seguimiento farmacoterapéutico al ingreso y al alta resuelve y previene problemas y favorece la información y satisfacción del paciente. Las limitaciones de personal impiden cumplir las demandas de la población (AU)

Introduction The objective is to assess a pharmaceutical care programme for heart transplant patients upon patient admission and discharge. Material y methods Observational study of heart transplant patients, performed during the first quarter of 2007. Upon admission, the patient was interviewed regarding home treatments, adherence, allergies and adverse effects, and his/her prescriptions were compared with the last discharge report (drug reconciliation). At time of discharge, treatment was checked against the last hospital prescription (reconciliation) and an informative report was drawn up and personally delivered to the patient. Subsequently, a satisfaction questionnaire was carried out by telephone. Drug-related problems were recorded using Atefarm® software. Results The programme was applied to 24 patients upon admission and 23 upon discharge. No drug interactions were detected. Treatment adherence was higher than 90%. 37.5% of patients informed of an adverse reaction. Medication-related problems were identified in 16 patients (45.7%) for 6.6% of medications, most of which (38%) were for infection prophylaxis; medication omission was the most frequently-detected error. Positive evaluation of the information that was received was higher than 90% (AU)