Análisis de los fallos detectados en el proceso de dispensación de medicamentos y los factores contribuyentes

  1. Teresa Bermejo Vicedo
  2. Ana M. Álvarez Díaz
  3. Eva Delgado Silveira
  4. Mª Esther Gómez de Salazar López de Silanes
  5. Covadonga Pérez Menéndez Conde
  6. M. del Rosario Pintor Recuenco
  7. Jaume Serna Pérez
  8. Teresa Mendoza Jiménez

ISSN: 1888-6116

Year of publication: 2009

Volume: 20

Issue: 3

Pages: 194-199

Type: Article

More publications in: Trauma


SCImago Journal Rank

  • Year 2009
  • SJR Journal Impact: 0.104
  • Best Quartile: Q4
  • Area: Orthopedics and Sports Medicine Quartile: Q4 Rank in area: 182/220


Objetive: To calculate the prevalence of failures in 5 medication-dispensing systems (DS) that cause dispensing errors and their contributing factors (CF). Methods: Prospective observational study. All the steps were reviewed in 5 DS: Stock, Automated dispensing systems (ADS) associated to Computerized Prescription Order Entry (CPOE ADS), no- CPOE ADS, CPOE Unitary-Dose dispensing systems (UDDS) and no-CPOE UDDS. Dispensing errors and their causing system-failure and the potential CFs were identified. Results: 2,181 failures were detected among 54,169 opportunities. Failure-rates were: Stock, 10.7%; CPOE ADS, 2.9%; no-CPOE ADS, 20.7%; CPOE UDDS, 2.2% and no-CPOE UDDS, 3.7%. The most frequent failure was: Stock, order preparation; CPOE ADS and no-CPOE ADS, ADS filling; CPOE UDDS and no-CPOE UDDS, unit dose cart filling. The most frequent dispensing error was: Stock, CPOE ADS and no-CPOE ADS, omission; CPOE UDDS, different amount of drug and no-CPOE UDDS, extra medication. The most frequent contributing factor was: Stock, CPOE ADS and no-CPOE ADS, stockout/supply problems; CPOE UDDS, inexperienced personnel and deficient communication between professionals; no-CPOE UDDS, deficient communication. Conclusions: In this study we have identified the failures in the DSs, which will let us redesign the process and increase the security