Development of Medication Error Checking and Prevention System in Inpatient Dispensing Process at Banpong Hospital
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Abstract
Background: Medication errors significantly impact patient safety in hospitals, particularly in inpatient medication dispensing processes that involve multiple healthcare professionals. This study aimed to develop a medication error monitoring and prevention system in the inpatient dispensing process at Banpong Hospital.
Methods: This action research employed the PDCA quality improvement framework based on ISO 9001:2015 quality management guidelines in four phases, conducted at Banpong Hospital, Ratchaburi Province, from July 2024 to April 2025. The sample consisted of 41 healthcare professionals involved in the inpatient medication dispensing process. Research instruments included medication error record forms, inpatient medication safety checklists, and guideline adherence assessment forms. Data were analyzed using descriptive statistics and inferential statistics, including paired t-test and Chi-square test.
Results: After system implementation, the overall medication error rate decreased from 8.75 to 3.12 errors per 1,000 patient-days. Prescribing errors decreased by 60.5%, pre-dispensing errors by 67.2%, and dispensing errors by 69.3%. Errors involving high-alert medications and look-alike/sound-alike (LASA) medications decreased by 80.0% and 81.2%, respectively. The severity of medication errors decreased significantly ( = 12.56, p = 0.003), with level no patient impact increasing from 63.79% to 86.36% and level patient impact decreasing from 36.21% to 13.64%. Increased monitoring was observed post-implementation.
Conclusion: The developed medication error monitoring and prevention system effectively reduced both medication error rates and severity levels. Long-term follow-up is recommended to evaluate system sustainability, and the system should be expanded to other hospitals
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