Medication errors and drug-dispensing systems in a hospital pharmacy.

Pharmacies permeate and interconnect various actions developed in different sectors within the complex process of the use of drugs in a hospital. Dispensing failures mean that a breach has occurred in one of the last safety links in the use of drugs. Although most failures do not harm patients, their existence suggests fragility in the process and indicates an increased risk of severe accidents. Present concepts on drug-related incidents may be classified as side effects, adverse effects, and medication errors. Among these are dispensing errors, usually associated with poor safety and inefficient dispensing systems. Factors associated with dispensing errors may be communication failures, problems related to package labels, work overload, the physical structure of the working environment, distraction and interruption, the use of incorrect and outdated information sources and the lack of patient knowledge and education about the drugs they use. So called banal dispensing errors reach significant epidemiological levels. The purpose of this paper, which is part of a study on the occurrence of dispensing errors in the pharmacy of a large hospital, is to review the main concepts that guide studies on adverse effects and to provide an update on dispensing errors.

[1]  H. Manasse Medication use in an imperfect world: drug misadventuring as an issue of public policy, Part 2. , 1989, American journal of hospital pharmacy.

[2]  K N Barker,et al.  Research on drug-use-system errors. , 1995, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[3]  T W Nolan,et al.  Reducing adverse drug events: lessons from a breakthrough series collaborative. , 2000, The Joint Commission journal on quality improvement.

[4]  K N Barker,et al.  Effect of an automated bedside dispensing machine on medication errors. , 1984, American journal of hospital pharmacy.

[5]  A. D. Hurlé Acontecimientos adversos por medicamentos: una patología emergente , 2004 .

[6]  M. O. Faddis Eliminating Errors in Medication , 1939 .

[7]  H R Manasse,et al.  Medication use in an imperfect world: drug misadventuring as an issue of public policy, Part 1. , 1989, American journal of hospital pharmacy.

[8]  E. Ribeiro "Dose unitária": sistema de distribuição de medicamentos em hospitais , 1993 .

[9]  P. Corey,et al.  Incidence of Adverse Drug Reactions in Hospitalized Patients , 2012 .

[10]  Suely Rozenfeld Farmacovigilância: elementos para a discussão e perspectivas , 1998 .

[11]  Silvia Helena de Bortoli Cassiani,et al.  ERROS NA MEDICAÇÃO: ANÁLISE DAS SITUAÇÕES RELATADAS PELOS PROFISSIONAIS DE ENFERMAGEM , 2000 .

[12]  Edson Perini,et al.  Erros de medicação: quem foi? , 2003 .

[13]  D. C. Mcleod,et al.  Comparison of a Traditional and Unit Dose Drug Distribution System in a Nursing Home , 1971 .

[14]  C. Pamer,et al.  Retrospective analysis of mortalities associated with medication errors. , 2001, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[15]  Gil Sevalho Uma abordagem histórica das representações sociais de saúde e doença , 1993 .

[16]  Suely Rozenfeld,et al.  A epidemiologia do medicamento: princípios gerais , 1989 .

[17]  L. Kohn,et al.  To Err Is Human : Building a Safer Health System , 2007 .

[18]  J. H. Carranza,et al.  Errores de medicación , 2004 .

[19]  K. Barker The effects of an experimental medication system on medication errors and costs. I. Introduction and errors study. , 1969, American journal of hospital pharmacy.

[20]  A. Wall,et al.  Book ReviewTo Err is Human: building a safer health system Kohn L T Corrigan J M Donaldson M S Washington DC USA: Institute of Medicine/National Academy Press ISBN 0 309 06837 1 $34.95 , 2000 .