Studies of Medication Errors in Pharmaceutical Services for Out Patients in the Pharmacy Work Group, Loei Hospital.

Abstract

This descriptive study aimed to study medications errors in pharmaceutical servicesfor out-patients at Loei Hospital and determine the causes of the aforementioned errors overa study period of 12 months (October 2014 – September 2015). The data collection instruments were composed of the medication errors record forms and prescription forms. Data wereanalyzed by using medication errors incidence rates. The results of the study showed that: 1)144 prescription errors (0.6509 times per 1,000 prescription forms). There was a total of 100prescription instruction errors (0.4522 times per 1,000 prescription forms), 16 prescription wrongdrug errors (0.0723 times per 1,000 prescription forms) and 7 prescription forms ordering thedispensing of medications to which patients are allergic (0.0317 times per 1,000 prescriptionforms). These prescription errors did not reach patients because pharmacists checked themedications and discovered errors before dispensing them. 2) 3,193 pre-dispensing errors thatdid not reach patients were encountered (14.4421 times per 1,000 prescription forms); Of thisnumber, the top three errors were 1,312 drugs errors (5.9325 times per 1,000 prescriptionforms), 497 quantity errors (2.2473 times per 1,000 prescription forms). And 305 times ofincomplete medications (1.3791 times per 1,000 prescription forms). And 3) dispensing errorsdivided into the following: 3.1) 57 errors at level C severity that reached patients but unlikelyto cause harm to them (0.2577 times per 1,000 prescription forms). Of this number, the topthree errors were 15 incomplete dispensing according to doctor’s orders (0.0678 times per1,000 prescription forms), 10 errors dispensed to the wrong patients (0.0452 times per 1,000prescription forms) and 7 medication wrong quantity errors (0.0317 times per 1,000 prescriptionforms); 3.2) 9 dispensing errors with severity at Level D were errors that could have necesscitated monitoring and/or intervention to preclude harm (0.0406 times per 1,000 prescriptionforms) and 6 wrong drugs dispensing errors (0.0271 times per 1,000 prescription forms), 2wrong dosage errors (0.009 times per 1,000 prescription forms), 1 error incomplete dispensingaccording to doctor’s order (0.0045 times per 1,000 prescription) and 3.3) 2 Level E errors thatoccurred and temporary harm with require further treatment/correction is wrong drug dispensingerror 2 times (0.009 times per 1,000 prescription form). Root cause analysis was performedto determine dispensing errors in dispensary units, excessive workloads negligence and inadequate personnel experience were the causes of pre-dispensing errors and dispensing errors.Similar medication names and shapes (Look a like sound a like) were also the external causesof medication errors.

Minor to severe dispensing errors in Pharmacy department, Loei hospital caused by internal factors such as workloads, negligence and personnel experience in addition to external factors such as similar medication names and shapes. This problems should be solved for further improvement and quality assurance.