Medication errors in inpatient pharmacy operations and technologies for improvement

Abstract

The inpatient pharmacy component of the medication-use process is complex and error prone. Its functioning relies on interactions among providers, patients, information, and technology, and the majority of medication errors are a direct result of the intrinsic complexity of these interactions. Technology is commonly deployed as part of medication error-reduction initiatives, affecting patients and providers alike. Therefore, principles that determine the influence of technological initiatives, such as human factors engineering and normal accident theory, must be addressed to ensure that technology is used safely in the inpatient pharmacy setting. This commentary discusses medication errors that occur during inpatient pharmacy operations, theories on why these errors occur, and technologies aimed at addressing these errors. The inpatient pharmacy functions as part of the greater medication-use process, which involves diagnosis, prescription, preparation, dispensing, administration, and monitoring. Inpatient pharmacies are primarily involved in the preparation and dispensing of medications, and the associated processes occur in three distinct steps: interpretation and transcription, preparation, and delivery. Each step is accomplished by people who are performing many different tasks at the same time. In addition to these functions, pharmacy is responsible for controlling the dispensing of drugs; communicating with physicians, nurses, and other staff; and ensuring rational and safe drug use.1 These tasks are rarely segregated within inpatient pharmacies and are often performed by the same individuals at the same time as they prepare medications for patient use.