Development of an Inpatient Dispensation System to Reduce Dispensing Errors in Phrachomklao Hospital, Phetchaburi Province

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Wassana Ramkaroon
Sudarat Chaichalerm
Ajchara Oumkrua


Dispensing errors are one of the most important mistakes in medical service; they result from failure to usecorrect drug-dispensing processes as specified on the prescription and may harm patients. This action research aimedto develop an inpatient dispensation system to reduce dispensing errors in Phrachomklao hospital. This researchwas carried out in the inpatient department. Data were collected by using incident dispensing error reports and afocus group discussion. Qualitative data were analyzed by content analysis and quantitative data were analyzed andreported using frequency, percentage and the independent t-test.The researcher identified dispensing problems and developed a more appropriate inpatient dispensation systemby using root cause analysis and a focus group discussion with stakeholders, including pharmacists, pharmacytechnicians and inpatient dispensing officer. The new dispensation system consists of an improved storage label,especially for look alike sound alike drug name (LASA); arrangement of drugs according to the type of disease;storing LASA drugs away from each other; storing drug bottles on a different floor; creating a pop-up alertprogram and different forms in the computer database according to the varying strength of drug dosages; establishingdouble-check guidelines in command off from physician’s drug order; and pre-packaging injectable antibiotic LASAs.The results show no significant difference in overall average inpatient dispensing errors between the old and newdispensation systems (p-value = 0.315). However, a significant reduction was found in terms of wrong medicinesdispensed and wrong item of medicine (p-value < 0.001).The findings of this study reveal that the development of an inpatient dispensation system was used inputfrom participatory stakeholders and root cause analysis and then applied to improve the system This resulted

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Ramkaroon W, Chaichalerm S, Oumkrua A. Development of an Inpatient Dispensation System to Reduce Dispensing Errors in Phrachomklao Hospital, Phetchaburi Province. J Public Hlth Dev [Internet]. 2014 Apr. 8 [cited 2024 Apr. 24];11(3):61-72. Available from:
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