Frequency, types, and potential clinical significance of medication-dispensing errors

Clinics

Volumn 64, Issue 1, 2009, Pages 11-16

  Bohand, Xavier ^a   Simon, Laurent ^a   Perrier, Eric ^a   Mullot, Hélène ^a   Lefeuvre, Leslie ^a   Plotton, Christian ^a  

^a PERCY MILITARY HOSPITAL   (France)

Author keywords

Adverse event; Drug error; Patient security; Risk management; Unit dose

Indexed keywords

AGED; ARTICLE; CARDIOVASCULAR DISEASE; EVALUATION; FEMALE; FRANCE; HOSPITAL ORGANIZATION; HOSPITAL PHARMACY; HUMAN; MALE; MEDICATION ERROR; PROSPECTIVE STUDY; STANDARD; STATISTICS;

AGED, 80 AND OVER; CARDIOVASCULAR DISEASES; FEMALE; FRANCE; HUMANS; MALE; MEDICATION ERRORS; MEDICATION SYSTEMS, HOSPITAL; PHARMACY SERVICE, HOSPITAL; PROSPECTIVE STUDIES;

EID: 58849095391     PISSN: 18075932     EISSN: None     Source Type: Journal    
DOI: 10.1590/S1807-59322009000100003     Document Type: Article

References (37)

1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine, National Academy Press, 1999.
2. Phillips DP, Christenfeld N, Glynn LM. Increase in US medication-error deaths between 1983 and 1993. Lancet. 1998;351:643-4.
3. Ferner RE, Aronson JK. Medication errors, worse than a crime. Lancet. 2000;355: 947-8.
4. Bates DW, Boyle DL, James Schneider MB, Leape LL. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10:199-205.
5. Kopp BJ, Erstad BL, Allen ME, Theodorou AA, Priestley G. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med. 2006;34:415-25.
6. Bates DW, Cullen DJ , Laird N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug events. Implication for prevention. JAMA. 1995;274:29-34.
7. Lisby M, Nielsen LP, Mainz J. Errors in the medication process: frequency, type, and potential clinical consequences. Int J Qual Health Care. 2005;17:15-22.
8. Taylor J, Gaucher M. Medication selection errors made by pharmacy technicians in filling unit dose orders. Can J Hosp Pharm. 1986;39:9-12.
9. Jornet Montana S, Canadell Vilarasa L, Calabuig Muoz M, Riera Sendra G, Vuelta Arce M, Bardaji Ruiz A, et al. Detection and classification of medication errors at Joan XXIII University Hospital. Farm Hosp. 2004;28:90-6.
10. Beso A, Franklin BD, Barber N. The frequency and potential causes of dispensing errors in a hospital pharmacy. Pharm World Sci. 2005;27:182-90.
11. Cina JL, Gandhi TK, Churchill W, Fanikos J, McCrea M, Mitton P, et al. How many hospital pharmacy medication dispensing errors go undetected? Jt Comm J Qual Patient Saf. 2006;32:73-80.
12. Rolland P. Occurrence of dispensing errors and efforts to reduce medication errors at the Central Arkansas Veteran's Healthcare System. Drug Saf. 2004;27:271-82.
13. Klein EG, Santora JA, Pascale PM, Kitrenos JG. Medication cart-filling time accuracy, and cost with an automated dispensing system. Am J Hosp Pharm. 1994;51:1193-6.
14. American society of hospital pharmacists. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993;50:305-14.
15. Parker PF. Drug distribution in hospitals. Unit-dose systems reduce error, increase efficiency. Hospitals. 1968;42:65-72.
16. Taxis K, Dean B, Barber N. Hospital drug distribution systems in the UK and Germany. A study of medication errors. Pharm World Sci. 1999;21:25-31.
17. Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm. 2002;59:436-46.
18. Anacleto TA, Perini E, Rosa MB, Cesar CC. Drug-dispensing errors in the hospital pharmacy. Clinics. 2007;62: 243-50.
19. Anacleto TA, Perini E, Rosa MB, Cesar CC. Medication errors and drug-dispensing systems in a hospital pharmacy. Clinics. 2005;60:325-32.
20. nd ed. 2007. p. 680.
21. National Coordinating Council for Medication Error Reporting and Prevention. Recommendations to enhance accuracy of dispensing medications. 1999, 2005. Available from http://www.nccmerp.org/council/council1999-03-19.html.
22. Facchinetti NJ, Campbell GM, Jones DP. Evaluating dispensing error detection rate in a hospital pharmacy. Med Care. 1999;37:39-43.
23. Ness JE, Sullivan SD, Stergachis A. Accuracy of technicians and pharmacists in identifying dispensing errors. Am J Hosp Pharm. 1994;51:354-7.
24. Spooner SH, Emerson PK. Using hospital pharmacy technicians to check unit dose carts. Hosp Pharm. 1994;29:433-7.
25. Ambrose PJ, Saya FG, Lovett LT, Tan S, Adams DW, Shane R. Evaluating the accuracy of technicians and pharmacists in checking unit dose medication cassettes. Am J Health Syst Pharm. 2002;59:1183-8.
26. Aspden P, Wollcott J, Bootman JL, Cronenwett LR, editors. Committee on Identifying and Preventing Medication Errors. Preventing medication errors. Institute of Medicine. Whasington, DC: National Academy Press, 2007. p. 393.
27. Scarsi KK, Fotis MA, Noskin GA. Pharmacist participation in medical rounds reduces medication errors. Am J Health Syst Pharm. 2002;59:2089-92.
28. Bond Ca, Rahel C, Franke T. Medication errors in United States hospitals. Pharmacotherapy. 2001;21:1023-36.
29. Weant KA, Cook AM, Armitstead JA. Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry. Am J Health Syst Pharm. 2007;64:526-30.
30. Fontan JE, Maneglier V, Nguyen VX, Loirat C, Brion F. Medication errors in hospitals: computerized unit dose drug dispensing system versus ward stock distribution system. Pharm World Sci. 2003;25:112-7.
31. Mirco A, Campos L, Falcao F, Nunes JS, Aleixo A. Medication errors in an internal medicine department. Evaluation of a computerized prescription system. Pharm World Sci. 2005;27:351-2.
32. Poon EG, Cina JL, Churchill W, Patel N, Featherstone E, Rothschild JM, et al. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. Ann Intern Med. 2006;145:426-34.
33. Scott O, Caldwell R. Dispensing error rate after implementation of an automated pharmacy caroussel system. Am J Health Syst Pharm. 2007;64:1427-31.
34. Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43.
35. Desselle SP. Certified pharmacy technicians' views on their medication preparation errors and educational needs. Am J Health-Syst Pharm. 2005;62:1992-7.
36. Navaneethan S, Venkatesh S, Nannapaneni S, Shrivastava R. Educational intervention: a tool for decreasing medication errors. Int J Qual Health Care. 2005;17:83.
37. Mullot H, Simon L, Cannonge B, Lefeuvre L, Bohand X. Challenging drug iatrogenic disease and iatrogenic risk : a military hospital experience of a program training for nurses. J Pharm Belg. 2008;63:43-50. [in press]