title: Medication incidents related to automated dose dispensing in community pharmacies and hospitals--a reporting system study.
abstract: BACKGROUND
  Automated dose dispensing (ADD) is being introduced in several countries and the use of this technology is expected to increase as a growing number of elderly people need to manage their medication at home. ADD aims to improve medication safety and treatment adherence, but it may introduce new safety issues. This descriptive study provides insight into the nature and consequences of medication incidents related to ADD, as reported by healthcare professionals in community pharmacies and hospitals.
  
  
  METHODS
  The medication incidents that were submitted to the Dutch Central Medication incidents Registration (CMR) reporting system were selected and characterized independently by two researchers.
  
  
  METHODS
  Person discovering the incident, phase of the medication process in which the incident occurred, immediate cause of the incident, nature of incident from the healthcare provider's perspective, nature of incident from the patient's perspective, and consequent harm to the patient caused by the incident.
  
  
  RESULTS
  From January 2012 to February 2013 the CMR received 15,113 incidents: 3,685 (24.4%) incidents from community pharmacies and 11,428 (75.6%) incidents from hospitals. Eventually 1 of 50 reported incidents (268/15,113 = 1.8%) were related to ADD; in community pharmacies more incidents (227/3,685 = 6.2%) were related to ADD than in hospitals (41/11,428 = 0.4%). The immediate cause of an incident was often a change in the patient's medicine regimen or relocation. Most reported incidents occurred in two phases: entering the prescription into the pharmacy information system and filling the ADD bag.
  
  
  CONCLUSIONS
  A proportion of incidents was related to ADD and is reported regularly, especially by community pharmacies. In two phases, entering the prescription into the pharmacy information system and filling the ADD bag, most incidents occurred. A change in the patient's medicine regimen or relocation was the immediate causes of an incident.
authors: Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands; Royal Dutch Pharmacists Association (KNMP), Den Haag, The Netherlands.
authors: Ka-Chun
authors: KC
authors: Cheung
authors: Department of Hospital Pharmacy, Erasmus MC, Rotterdam, The Netherlands.
authors: Patricia M L A
authors: PM
authors: van den Bemt
authors: Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands.
authors: Marcel L
authors: ML
authors: Bouvy
authors: Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands.
authors: Michel
authors: M
authors: Wensing
authors: Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands; Royal Dutch Pharmacists Association (KNMP), Den Haag, The Netherlands; Department of Clinical Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands.
authors: Peter A G M
authors: PA
authors: De Smet
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001331:Automation; D000075202:Contraindications; D005260:Female; D006761:Hospitals; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008509:Medication Systems / Q000706:statistics & numerical data; D008875:Middle Aged; D009426:Netherlands; D010594:Pharmacies; D055553:Prescription Drugs; D012308:Risk Management
chemical_list: D055553:Prescription Drugs