Category: Professional Posters
Purpose: Medication errors are considered one of the most preventable causes of patient’s harm. It could happen at any stage of the medication use process including prescribing, preparation, dispensing, and administration. Dispensing is complex process involves multiple stages and the occurrence of any error in this process could threaten a patient's life. The objective of this study was to identify the prevalence and the severity level of dispensing errors reported in King Abdulaziz Medical City –Central Region (KAMC-CR) and King Abdullah Specialized Children’s Hospital (KASCH).
Methods: Dispensing Error Data were collected from King Abdulaziz Medical City (KAMC) reporting system- Safety Reporting System (SRS). In order to analyze Dispensing Errors, the cause of error was reviewed and classified them according to the cause. Also, categorization of errors is used which is developed by the ISMP and the ASHP. Wrong Practice Medication Errors class; any error by the pharmacist who is not following the hospital policy and procedure. For evaluating and categorizing medication error in the data, the NCC MERP Index is utilized.
Results: A total of 3017 safety reports were submitted to the safety reporting system during 2017and the dispensing errors reported was 448 (14.84%). While in 2018 nearly 2381 safety reports and a slightly higher percentage of dispensing errors were noted about 18%. Generally, KAMC and KASCH pharmacies have consistently low percentage of dispensing error not exceeding 0.01% of the total orders received. In 2017, the number of dispensing errors involving high alert medications was about 14.06% of total error reported in KASCH and 20%in KAMC and an similar percentage in 2018. The monthly reporting rate fluctuated by several factors such as holidays. After further analysis of 2017 reports, medication delay was the highest reason for dispensing errors accounts for 28% and 27.4% in both KASCH and KAMC respectively. Followed by reasons was incorrect medication accounts for 23% in KAMC, and 20.17% in KASCH for packaging issues of reports. In addition, a sub-analysis by the severity level was done. In 2017, 97.4% of the reports in KASCH and 97% in KAMC did not reach the patients while in 2018; about 98% in KAMC and 99% in KASCH. Only a minority about 1.1% in 2017 and 3.2% in 2018 did reach the patient.
Conclusion: The safety report system used as a tool for improvement in pharmaceutical care services and provide staff education to be more vigilant before dispensing medications. Overall low rate of dispensing error was observed in this study. Moreover, dispensing error increase during 2018 due to implementing Automated Dispensing Cabinet (ADC) in the hospital. Doing an annual analysis of the dispensing error helps to identify the frequency and predisposing factors to the occurrence of such errors and working accordingly to reduce these errors. We encourage staff to report medication error to have safe practice and just culture environment.