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

OBJECTIVE: To analyze the results of sentinel patient program to monitoring the  quality pharmacoterapeutic process in the hospitalized patient through  medication errors.

METHOD: Design: Observational, prospective and transversal study. Ambit: General hospital of 1,000 beds.

PERIOD: From May 2011 to June 2016.  Sample: Patients with treatment prescribe within 24 hours of being admitted  with 4 or more medications.

VARIABLES: 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.

RESULTS: 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.

CONCLUSIONS: 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.