[New technologies applied to the medication-dispensing process, error analysis and contributing factors].
OBJECTIVE
Calculate error prevalence occurred in different medication-dispensing systems, the stages of occurrence, and contributing factors.


METHODS
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.
Alvarez Díaz
A M
AM
Servicio de Farmacia, Hospital Universitario Ramón y Cajal, Madrid, Spain.
Delgado Silveira
E
E
Pérez Menéndez-Conde
C
C
Pintor Recuenco
R
R
Gómez de Salazar López de Silanes
E
E
Serna Pérez
J
J
Mendoza Jiménez
T
T
Bermejo Vicedo
T
T
D001331:Automation; D016303:Clinical Pharmacy Information Systems / Q000706:statistics & numerical data / Q000639:trends; D055695:Electronic Prescribing / Q000706:statistics & numerical data; D006769:Hospitals, General; D006785:Hospitals, University; D006801:Humans; D050316:Medical Order Entry Systems / Q000706:statistics & numerical data / Q000639:trends; D008508:Medication Errors / Q000145:classification / Q000517:prevention & control / Q000706:statistics & numerical data; D008510:Medication Systems, Hospital / Q000706:statistics & numerical data / Q000639:trends*; D011446:Prospective Studies; D012371:Robotics; D013030:Spain