Monitoring the quality of the hospital pharmacoterapeutic process by sentinel patient program

María José Fernández-Megía, Isabel Font Noguera, Matilde Merino Sanjuán, José Luis Poveda Andrés

To analyze the results of sentinel patient program to monitoring the  quality pharmacoterapeutic process in the hospitalized patient through  medication errors. Design: Observational, prospective and transversal study. Ambit: General hospital of 1,000 beds. From May 2011 to June 2016.  Sample: Patients with treatment prescribe within 24 hours of being admitted  with 4 or more medications. Medication error, drugs prescribed,  medications and doses dispensing, drugs administered. Safety indicators were  defined based on medication errors at each stage of the pharmacotherapeutic  process. Of the 746 patients studied, 334 had at least 1 medication error  (44.8%; IC95%: 41.7-47.8). In the 746 treatments, 564 medication errors were  detected (0.75 errors by patient; IC95%: 0.7-0.8). The safety indicators  (medication error by stage) were: 5.1% (38/746 patients) for omission of  allergy record; 2.3% (156/6 724 drugs) for prescription; 0.6% (38/6 724 drugs)  for validation, 2.6% for dispensing (142/5 465 drugs) y 3.7% (190/5  111 administered drugs observed) for administration. The temporal evolution of  the indicators, with graphs of statistical control showed stable processes, except  for the administration. The proposed improvement actions were of a training,  standardization and organizational type. The sentinel patient program provides an overview of the quality  of the pharmacotherapeutic process and promotes the safety culture at the  center. Statistical control charts have been a useful tool for monitoring  medication errors. The analysis of medication errors has served to propose  improvement actions in each stage of the pharmacotherapeutic process.