Análisis de los fallos detectados en el proceso de dispensación de medicamentos y los factores contribuyentes
- Teresa Bermejo Vicedo
- Ana M. Álvarez Díaz
- Eva Delgado Silveira
- Mª Esther Gómez de Salazar López de Silanes
- Covadonga Pérez Menéndez Conde
- M. del Rosario Pintor Recuenco
- Jaume Serna Pérez
- Teresa Mendoza Jiménez
ISSN: 1888-6116
Year of publication: 2009
Volume: 20
Issue: 3
Pages: 194-199
Type: Article
More publications in: Trauma
Abstract
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