Dispensing errors in a public cardiopulmonary hospital
Objective: To identify and evaluate the frequency of types of medication dispensing errors and their potential causes, in a public cardiopulmonary hospital.
Methods: This was a prospective observational study carried out at a hospital pharmacy care to inpatients of a public cardiopulmonary hospital in the period from September to November 2014. After considering the separated medicines, dispensing errors were collected in a proper form, tabulated in spreadsheets (Excel) and presented by management tools: Pareto analysis to evaluate the frequency of the types of errors; Ishikawa diagram for evaluation the potential causes of errors; and indicator "error rate in dispensing drugs" to measure process performance.
Results: Were found 95 errors in dispensing drugs of 1971 separated prescriptions that were categorized as "unidentified or unreadable" (29.5%), "overdose" (18.9%), "omission dose" (17.9%), "dispensed differs from the prescribed" (14.7%), "expired" (12.6%) and "lower concentration" (6.3%). The error rate in dispensing medicines obtained was 0.74%. The potential causes of these errors are associated with improper storage, interruptions in the separation procedure, lack of standardization of procedures; memory lapses and lack of continuing education.
Conclusion: It was observed in the field and in the literature that the errors in dispensing drugs is a permanent risk in hospitals. Thus this process needs to be continuously evaluated. The management tools used assisted in identifying, analyzing and measuring the results being useful in monitoring the dispensing process for improvement.
The authors hereby transfer, assign, or otherwise convey to RBFHSS: (1) the right to grant permission to republish or reprint the stated material, in whole or in part, without a fee; (2) the right to print republish copies for free distribution or sale; and (3) the right to republish the stated material in any format (electronic or printed). In addition, the undersigned affirms that the article described above has not previously been published, in whole or part, is not subject to copyright or other rights except by the author(s), and has not been submitted for publication elsewhere, except as communicated in writing to RHFHSS with this document.
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License (CC-BY-NC-ND) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
This journal permits and encourages authors to post and archive the final pdf of the articles submitted to the journal on personal websites or institutional repositories after publication, while providing bibliographic details that credit its publication in this journal.