HS-09-OF 5 Dispensing Errors: Preventable Medication Errors by Pharmacists in Outpatient Department, A University Hospital, Bangkok, Thailand Susi Ari Kristina 1,2 , Patcharin Supapsophon 3 , 1 Social, Economics and Administrative Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand 2 Management and Community Pharmacy, Faculty of Pharmacy, Gadjah Mada University, Yogyakarta, Indonesia Cha-oncin Sooksriwong 1 3 Ramathibodi Hospital, Bangkok, Thailand Contact Address: susikristina@yahoo.com Abstract— The study aimed to determine the frequency and types of dispensing errors identified by pharmacists in the final checking; to explore the work flow of the medication dispensing system at the Outpatient Department (OPD) department University hospital; and to make recommendation for their prevention using system and human approach. Study design was descriptive retrospectively and setting in a University hospital. Medication error data were collected from medication error reporting program. Workflow, input, process and output observations were employed as well. Data analyzed by descriptive statistics. During 28 days of study length, it was recorded 20,775 prescriptions or 741 prescription/day. Dispensing errors reported were 348 events (1.67%). Prevalence of prescribing error, dosage error, and preparation error were 44.8%, 32.2% and 25.9% respectively. Average item per prescription 3.8 item/prescription. Potential errors can be occurred when items of drug increasing. Work flow of dispensing system in OPD University hospital already integrated with medication error reporting system. Pharmacists developed and implemented Medication Error Program as an instrument to report the medication dispensing errors routinely. Dispensing errors reported by pharmacists must be seen by the pharmacy institution-related as opportunities to identify areas for improvement. Prevalence of dispensing errors seems low but it is urgent to encourage staffs for detection and prevent more of potential harmful. Pharmacist role in building good system to encourage medication errors detection, reporting and prevention might be considered to ensure the commitment of patient safety. Keywords: dispensing errors; pharmacist; prevention management I. INTRODUCTION Patient safety has become a major concern since the November 1999 release of the Institute of Medicine’s (IOM) report, “To Err Is Human” (1, 2) . The IOM’s report in 2006 indicated that medication errors are among the most common medical errors, harming at least 1.5 million people every year. The reports concluded that 400,000 preventable drug-related injuries occur each year in hospitals. The report noted that these are likely underestimates because the data excluded errors of omission such as the failure to prescribe medications for which there is an evidence base for the ability to reduce morbidity and morbidity (3) . Medication errors compromise patient confidence in the health-care system and increase health-care costs (4) . The problems and sources of medication errors are multidisciplinary and multi factorial (5) . Errors occur maybe from lack of knowledge, substandard performance and mental lapses, or defects or failures in systems (6). Many medication errors are probably undetected since many medication errors maybe minimal consequence that adversely affected a patient. However, medication errors result in serious impact on patient’s morbidity and mortality (7) . System enhancements and the checks and balances needed to proactively prevent medication errors as pharmacists and technicians prepare, dispense, and monitor the effects of medications. To prevent medications errors, change and improve the system is needed, not rely on changing people (8) . Effective systems for prescribing, dispensing, and administering medications should be established with safeguards to prevent errors. Dispensing errors are usually associated with poor safety and inefficient dispensing systems (9) . Currently, medication errors reporting program in a University hospital is still developed and improved, using medication error software program, particularly for identify dispensing error types. The center of reporting placed in 2nd floor outpatient department, and established at November 2011. Based on these fact, we conducted the study about medication errors, how to prevent using system and human approach. The study aimed to determine the frequency and types of dispensing errors identified by pharmacists in the final checking; to explore the work flow of the medication dispensing system at the Outpatient Department (OPD) department University hospital; and to make recommendation for their prevention using system and human approach. II. METHOD A. Study design The study was descriptive retrospectively. The study was conducted in two part. The first, focus on analyzing the frequency of dispensing errors and classifying the errors identified at the final checking Secondly, concern on observation of work-flow of dispensing system in OPD and interview to Head of OPD during study period to arrange the recommendation for errors prevention.