Dispensing and Administration Errors after Conversion from Unit Dose Drug Distribution to Daily Dose Drug Distribution SystemsS. Leelasiriwilas, J. Pongwecharak,* P. Wongpoowarak and S. Ngor-suraches
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The study compared frequency of dispensing errors (DE) and administration errors (AE) occurring in unit dose drug distribution (UDDD) and daily dose drug distribution (DDDD) systems in a 25-bed ward of Surat Thani Regional Hospital. Pre-post evaluation design was used. Sample size was 2,000 drug doses. Main outcome measures were rates, types, causes, and severity of DE and AE at the time during which the UDDD system operated and 4 weeks after introducing the DDDD system. Double checking and disguised-observation technique were employed to identify the errors. DE rate of the UDDD was significantly lower than that of the DDDD systems (5.2% vs. 7.0%, p = 0.012) while the AE rate in the UDDD system was significantly higher (17.9% vs. 11.3%, p < 0.0001). Of all, the highest frequency of DE was extra medication (55.9%) and was omitted medication (50.0%) for the UDDD and the DDDD systems, respectively. The corresponding figures for AE were wrong time errors (78.6% and 77.2%). The most frequent causes of the errors in both systems were in the transcription process (78.4% and 84.3%) for the DE, and at the stage of nurses preparing medication for administering (85.6% vs. 83.5%) for the AE. All errors in both systems resulted in no harm to patients. In conclusion, DE were more common with the DDDD than with the UDDD systems, and vice versa for AE. Changing from the UDDD to DDDD systems did not significantly increase serious DE and AE.
Keyword:
Unit Dose , Drug Distribution Systems ,dispensing errors ,administration errors ,DDDD,UDDD,Surat Thani, transcription
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