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      Medication dispensing errors at a public pediatric hospital Translated title: Errores de despacho de medicamentos en un hospital público pediátrico Translated title: Erros de dispensação de medicamentos em um hospital público pediátrico

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          Abstract

          OBJECTIVE: assess the safety of medication dispensing processes through the dispensing error rate. METHOD: Cross-sectional study carried out at a pharmaceutical service of a pediatric hospital in Espírito Santo, Brazil. Data collection was performed between August and September 2006, totaling 2620 prescribed medication doses. Any deviation from the medical prescription in dispensing medication was considered a dispensing error. THE CATEGORIES OF MEDICATION ERRORS WERE: content, labeling, and documentation errors. The dispensing error rate was computed by dividing the number of errors by the total of dispensed doses. RESULTS: From the 300 identified errors, 262 (87.3 %) were content errors. The rate of errors in the labeling and documentation categories was 33 (11%) and 5 (1.7%), respectively. CONCLUSION: The total dispensing error rate was higher than rates reported in international studies. The most frequent category was "content error".

          Translated abstract

          OBJETIVO: Evaluar la seguridad en el despacho de medicamentos a través de la determinación de la tasa de errores de despacho. MÉTODOS: Estudio transversal que evaluó 2620 dosis de medicamentos despachados entre agosto y septiembre de 2006 en un servicio de farmacia de un hospital pediátrico del Estado de Espíritu Santo, Brasil. Los errores de despacho fueron definidos como cualquier desvío ocurrido entre lo despachado y lo prescrito en la receta médica. Los errores fueron categorizados en contenido, rótulo y documentación. La tasa de error de despacho fue calculada dividiendo el número de errores total por el número total de dosis despachadas. RESULTADOS: de los 300 errores identificados, 262 (87,3 %) fueron de contenido. En las categorías errores de rótulo la tasa fue de 33 (11%) y 5 (1.7%) en la de errores de documentación. CONCLUSIÓN: la tasa total de errores de despacho fue elevada cuando se compara con la descrita en estudios internacionales. La categoría de error más frecuente fue la de "error de contenido".

          Translated abstract

          Avaliar a segurança na dispensação de medicamentos através da determinação da taxa de erros de dispensação constituiu o objetivo deste trabalho. O método utilizado foi o estudo transversal que avaliou 2 620 doses de medicamentos dispensados entre agosto e setembro de 2006, em um serviço de farmácia de um hospital pediátrico do Espírito Santo. Os erros de dispensação foram definidos como qualquer desvio entre o dispensado e o prescrito na receita médica. Os erros foram categorizados em conteúdo, rotulagem e documentação. A taxa de erro de dispensação foi calculada dividindo o número de erros total/total de doses dispensadas. Os resultados mostraram que, dos 300 erros identificados, 262 (87,3%) foram de conteúdo. Nas categorias erros de rotulagem a taxa foi de 33 (11%) e 5 (1,7%) na de erros de documentação. Concluiu-se que a taxa total de erros de dispensação foi elevada quando comparada à descrita em estudos internacionais. A categoria de erro mais freqüente foi a de erro de conteúdo.

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          Human error: models and management

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            Fundamentals of medication error research.

            Types of medication errors are defined, error detection techniques are described, and the validity of several medication error studies is evaluated. A medication error is generally defined as a deviation from the physician's medication order as written on the patient's chart. In hospitals, medication errors occur at a rate of about one per patient per day. A dispensing error is one made by pharmacy staff when distributing medications to nursing units or directly to patients in an ambulatory-care pharmacy; the error rates for doses dispensed via the cart-filling process range from 0.87% to 2.9%. Categories of medication errors should be operationally defined before an investigation, and any allowable deviations from the physician's order should be clearly stated. Fourteen error category definitions are presented. Methods for detecting medication errors include anonymous self-reports (questionnaires), incident reports, the critical-incident technique (analyses of a large number of individual errors to identify common causal factors), and direct observation (including the disguised-observation and participant observer techniques). Observation is the best error detection method in terms of accuracy. Results of medication error studies were examined for validity and classified into one of four categories: (A) results should be accepted as reported, (B) results overestimate or underestimate the truth by a known amount, (C) results overestimate the truth by an unknown amount, and (D) results should not be accepted. All studies examined for validity used observation as the error detection technique. The following guidelines for observation-based medication error studies were established: The observer should follow the subject to the patient's bedside, the observer should witness patient consumption of each dose, the observer should not be familiar with patient drug regimens before observation, operational definitions must be used, and having an error validation committee can be advantageous. Future studies are needed that focus on the identification and testing of new error prevention methods that use the techniques described.
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              The frequency and potential causes of dispensing errors in a hospital pharmacy.

              To determine the frequency and types of dispensing errors identified both at the final check stage and outside of a UK hospital pharmacy, to explore the reasons why they occurred, and to make recommendations for their prevention. A definition of a dispensing error and a classification system were developed. To study the frequency and types of errors, pharmacy staff recorded details of all errors identified at the final check stage during a two-week period; all errors identified outside of the department and reported during a one-year period were also recorded. During a separate six-week period, pharmacy staff making dispensing errors identified at the final check stage were interviewed to explore the causes; the findings were analysed using a model of human error. Percentage of dispensed items for which one or more dispensing errors were identified at the final check stage; percentage for which an error was reported outside of the pharmacy department; the active failures, error producing conditions and latent conditions that result in dispensing errors occurring. One or more dispensing errors were identified at the final check stage in 2.1% of 4849 dispensed items, and outside of the pharmacy department in 0.02% of 194,584 items. The majority of those identified at the final check stage involved slips in picking products, or mistakes in making assumptions about the products concerned. Factors contributing to the errors included labelling and storage of containers in the dispensary, interruptions and distractions, a culture where errors are seen as being inevitable, and reliance on others to identify and rectify errors. Dispensing errors occur in about 2% of all dispensed items. About 1 in 100 of these is missed by the final check. The impact on dispensing errors of developments such as automated dispensing systems should be evaluated.
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                Author and article information

                Journal
                rlae
                Revista Latino-Americana de Enfermagem
                Rev. Latino-Am. Enfermagem
                Escola de Enfermagem de Ribeirão Preto / Universidade de São Paulo (, SP, Brazil )
                0104-1169
                1518-8345
                October 2008
                : 16
                : 5
                : 812-817
                Affiliations
                [02] orgnameHospital Infantil Alzir Bernadino
                [01] orgnameBahia Federal University Faculty of Pharmacy Brazil
                [03] orgnameUNIVIX orgdiv1Universidade Brasileira
                Article
                S0104-11692008000500003 S0104-1169(08)01600503
                bda3098e-f01e-4f6b-be0f-545071b5309c

                This work is licensed under a Creative Commons Attribution 4.0 International License.

                History
                : 08 July 2007
                : 08 August 2008
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 15, Pages: 6
                Product

                SciELO Revista de Enfermagem

                Categories
                Original Articles

                farmacia,atención farmacéutica,erros de medicação,farmácia,sistemas de medicação,assistência farmacêutica,medication errors,pharmacy,medication system,pharmaceutical care,errores de medicación,sistemas de medicación

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