Repackaged drugs used in hospitals: Look-alike medication errors waiting to happen

Medication errors (ME) related to similar packaging is a potential cause or failures that often appear underestimated if not ignored. There are drugs marketed pharmaceutical companies in pack types where identification data appear printed for a group of pills rather than each one, a requisite for inpatients. Inadequate labeling requires the pharmacy to repackaging them generating new potential medication errors because repackaged pills look-similar. Objective: To evaluate the extent to which look-alike repackaged drugs in hospitals are involved in the hospitalized patientu0027s pharmacotherapy. LASA errors reported to the hospital pharmacy pharmacovigilance unit by health care professionals in our center were also evaluated. Method: A longitudinal, prospective, observational study of four weeks was designed concerning the repackaging process of inappropriate packaged medications to be dispensed to inpatients. It was carried out in a tertiary hospital (1,350 beds). Pharmacotherapy prescribed to adult admitted patients was daily evaluated (410 beds). Pharmacists checked the number of repackaged look-alike drugs prescribed to these patients and look-alike repackaged medications dispensed as a result of these prescriptions. Moreover, we checked the number of errors reported to the pharmacy department pharmacovigilance unit related to look-alike drugs over the last two years (2015 and 2016) and how many of them involved look-alike repackaged medications. Time consumed in repackaging pills was also evaluated. Results: Pharmacotherapy of 7,182 inpatients was analyzed. Of them, 3,615 (50.3%) received at least one repackaged pill. At the time of the study, there were 459 different solid oral drugs available in the pharmacy, of which 108 (23.5%) were not individually packaged which had to be repackaged before dispensing. During the study, physicians prescribed 5,361 different oral solid medications that needed to be repackaged in the pharmacy because they were not marketed in unit-dose (244 daily on average). These prescriptions led to dispense 7,550 repackaged pills that looked similar generating avoidable new potential medication errors in our hospital (on average, 343 repackaged pills daily were dispensed to the wards included in the study). Moreover, when consulting the pharmacovigilance unit ME registry from January 2015 to December 2016, there were 19 errors related to medications wrongly selected of which 15 were considered LASA medication errors, none of them involving repackaged drugs. As for the inefficiency generated by this process, the number of drugs repackaged for dispensing to the whole hospital (1,350 beds) during the study. There were a total of 13,758 pills repackaged for being dispensed to inpatients (687.9 daily on average). Using the repackage automatic device files, we could calculate the median time daily consumed by a pharmacy technician. According to this record 80 minutes approximately were daily wasted dedicated to do this avoidable and risky activity. Conclusion: This study highlights the previous undescribed high rate of inadequate packaging and intimidation of oral solid medicines for their use in hospitals