• 作者：A.M. Á ; lvarez Dí ; az ; E. Delgado Silveira ; C. Pé ; rez Mené ; ndez-Conde ; R. Pintor Recuenco ; E. Gó ; mez de Salazar Ló ; pez de Silanes ; J. Serna Pé ; rez ; T. Mendoza Jimé ; nez ; T. Bermejo Vicedo ; ^{tbermejo.hrc@salud.madrid.org}
• 关键词：Error de dispensació ; n ; Error de medicació ; n ; Sistemas de distribució ; n de medicamentos ; Proceso farmacoterapé ; utico ; Calidad
• 刊名：Farmacia Hospitalaria
• 出版年：2010
• 期刊代码：pca388_11306343
• 类别：pha
• 出版时间：March-April 2010
• 卷：34
• 期：2
• 页码：59-67
• 文件大小：182 K

Objective

Calculate error prevalence occurred in different medication-dispensing systems, the stages of occurrence, and contributing factors.

Methodology

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.

Results

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.

Conclusions

Applying new technologies to the dispensing process has increased its safety, particularly, implementation of CPOE has enabled to reduce dispensing errors.