Category: Federal Forum Posters
Purpose: Medication errors can occur at any stage of drug management and use, which can be a threat to the safety of patients, as well as cause additional medical costs, resulting in socio-economic cost losses. Dispensing error is defined as a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient. The aim of this quality improvement activity was to reduce the rate of dispensing error by 30% to contribute to patient safety by analyzing the types of errors that may occur during the preparation and administration phase.
Methods: From May to September 2016, we analyzed dispensing errors by type, work schedule and pharmacists’ working experience by reviewing the dispensing error report. The major causes of errors were identified through data collection and quality improvement activity was initiated to reduce dispensing errors. These activities included conducting preventive education on dispensing errors, updating educational material, improving the environment of dispensing room, preventing filling errors, supplementing IT system, standardizing of inspection methods and conducting double inspection for accurate preparation of medicines. Then from May to September 2017, the number of dispensing errors after the improvement activity was investigated and the rate of dispensing errors was compared before and after quality improvement activity.
Results: The total number of prescriptions was 944,455 before and 977,273 after the quality improvement activity, while the number of dispensing errors was 50 and 33 before and after the quality improvement activity, respectively. The rate of error decreased significantly from 0.0053% to 0.0034% after the quality improvement activity (p=0.011). The most common dispensing errors by category were dispensing wrong quantity, wrong drug, wrong strength and wrong dosage form. By type of error, there were significant decreases after quality improvement activity in quantity errors (p=0.016) and dosage form errors (p=0.019). By type of work schedule, the rate of errors was higher in the order of holidays, weekdays and nights, and there was a significant decrease in weekdays (p=0.042) compared to holidays and nights.
Conclusion: As a result of the improvement activity, the error rate was reduced by 32.6% which met the goal of reducing errors by 30%, and it was confirmed that the quality improvement activity was effective in preventing the dispensing error. It is expected that the quality of patient safety and medical care will be improved by reducing dispensing errors through continuing interest, education and process improvement even after the quality improvement activity.