Calculate error prevalence occurred in different medication-dispensing systems, the stages of occurrence, and contributing factors.
Prospective observational study. The staging of the dispensing process were reviewed in five dispensing systems: Stock, Unitary-Dose dispensing systems (UDDS) without Computerized Prescription Order Entry (CPOE), CPOE-UDDS, Automated Dispensing Systems (ADS) without CPOE and CPOE-ADS. Dispensing errors were identified, together with the stages of occurrence of such errors and their contributing factors.
2,181 errors were detected among 54,169 opportunities of error. Error-rate: Stock, 10.7 % ; no-CPOE-UDDS, 3.7 % , CPOE-UDDS, 2.2 % , no-CPOE-ADS, 20.7 % ; CPOE-ADS, 2.9 % . Most frequent stage when error occurs: Stock, preparation of order; no-CPOE-UDDS and CPOE-UDDS, filling of the unit dose cart; no-CPOE-ADS and CPOE-ADS, filling of the ADS. Most frequent error: Stock, no-CPOE-ADS and CPOE-ADS, omission; CPOE-UDDS, different amount of drug and no-CPOE-UDDS, extra medication. Contributing factor: Stock, CPOE-ADS and no-CPOE-ADS, stock out/supply problems; CPOE-UDDS, inexperienced personnel and deficient communication system between professionals; no-CPOE-UDDS, deficient communication system between professionals.
Applying new technologies to the dispensing process has increased its safety, particularly, implementation of CPOE has enabled to reduce dispensing errors.