Measures for Prevention of Dispensing Errors Based on ISO 9001 Certified Management System and Their Evaluation

Abstract

We operate a quality management system for pharmacy practice whose aims are to achieve effective and safe pharmacotherapy for patients. ISO 9001 certification was obtained for the system in October 2003. In the following, we describe the measures against dispensing errors and the evaluation of their effectiveness. We divided dispensing errors into those noted by pharmacists other than those who did the dispensing and what we called “incidents”, which were dispensing errors discovered after medicines were given to patients. When incidents involved giving the wrong medication to patients, a report on corrective action was required. We also analyzed the factors in the occurrence of dispensing errors, devised actions to prevent them, and evaluated their effectiveness after they had been implemented.
The corrective actions lead to the prevention of similar incidents. Corrective actions in the form of visual aids on the dispensary shelves and supporting information reduced dispensing errors involving names and dosage forms of medicines. Though errors regarding the quantities of medicines were not decreased by these actions, they were significantly reduced by implementation of an error reporting system and preparation of a list of medicines giving details of their package sizes (i.e. number of tablets in a package). While the prevention of dispensing errors is not easy, our efforts suggested that the practice of the PDCA cycle using an ISO 9001 certified quality management system is useful in this regard.