A Comparison of Medication Errors Under the University of Kentucky Unit Dose System and Traditional Drug Distribution Systems in Four Hospitals

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Abstract
The University of Kentucky Hospital has operated a hospital-wide unit dose system for more than four years. The unit dose system was compared to traditional medication systems to determine whether the unit dose system permitted fewer medication errors to reach the patient. Two community and two university hospitals were selected for study. Medication error audits were performed on selected medical nursing units in each of the five hospitals. The criteria for hospital selection and the auditing methodology are described. There were significantly fewer medication errors reaching the patient in the unit dose system than in the conventional drug distribution systems studied. Although a significantly different pattern of errors of omission and commission was found among hospitals, major causes of errors included incorrect information source(s), omissions for no apparent reason, administration of wrong doses and failure to follow hospital automatic stop order policies. Also discussed is the possible clinical significance of the medication errors and the limitations of the error auditing methodology. The relationship of errors to the various components of the unit dose system is discussed in light of the results obtained from comparison hospitals.

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