Monitoring Medication Errors in Personalised Dispensing Using the Sentinel Surveillance System Method

Abstract

Objective

To assess the efficacy of a new quality control strategy based on daily randomised sampling and monitoring of a sentinel surveillance system (SSS) medication cart, in order to identify medication errors and their origin at different levels of the process.

Method

Prospective quality control study with one-year follow-up. An SSS medication cart was randomly selected once a week and double-checked before dispensing medication. Medication errors were recorded before the cart was taken to the relevant hospital ward. Information concerning complaints after receiving medication and 24-h monitoring was also noted. Type and origin of error data were assessed by a unit dose quality control group, which proposed relevant improvement measures.

Results

Thirty-four SSS carts were assessed, including 5130 medication lines and 9952 dispensed doses, corresponding to 753 patients. Ninety erroneous lines (1.8%) and 142 mistaken doses (1.4%) were identified at the pharmacy department. The most frequent error was dose duplication (38%) and its main cause was inappropriate management and forgetfulness (69%). Fifty medication complaints (6.6% of patients) were mainly due to new treatment at admission (52%), and 41 (0.8% of all medication lines), did not completely match the prescription (0.6% lines) as recorded by the pharmacy department. Thirty-seven (4.9% of patients) medication complaints due to changes at admission and 32 matching errors (0.6% medication lines) were recorded. The main cause also was inappropriate management and forgetfulness (24%). The simultaneous recording of incidences due to complaints and new medication coincided in 33.3%. In addition, 433 (4.3%) of dispensed doses were returned to the pharmacy department. After the unit dose quality control group conducted their feedback analysis, 64 improvement measures for pharmacy department nurses, 37 for pharmacists, and 24 for the hospital ward were introduced.

Conclusions

The SSS programme has proven to be useful as a quality control strategy to identify unit dose distribution system errors at initial, intermediate and final stages of the process, improving the involvement of the pharmacy department and ward nurses.