Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany

Am J Geriatr Pharmacother. 2008 Oct;6(4):212-9. doi: 10.1016/j.amjopharm.2008.10.005.


Objective: The aim of this study was to quantify and classify errors associated with the repackaging of residents' medications in long-term care facilities in Germany.

Methods: This was a prospective 8-week study conducted in 3 long-term care facilities. Pill organizers, each of which contained all repackaged solid oral dosage forms of long-term medications for a particular resident for an entire day, were inspected and checked against residents' medication sheets by the investigator-pharmacist. On agreement between the pharmacist and the registered nurse responsible for residents' medications, all errors were rectified before medications were administered. The primary study measure was the overall rate of incorrectly repackaged medications relative to all repackaged medications. Secondary measures were the proportion of all pill organizers with medication errors and the proportion of residents who would have been affected by these errors. Errors were categorized by type as follows: wrong time of administration, wrong dose, wrong medication, omission of a medication, extra dose, incorrect halving of tablets, and damaged medication.

Results: One hundred ninety-six residents were included in the study, representing 8798 daily pill organizers and 48,512 inspected medications. Residents received a mean of 5.4 solid oral dosage forms of long-term medications per day. Six hundred forty-five errors were detected, for an error rate of 1.3%; the errors involved 7.3% of daily pill organizers and 53.0% of residents. The largest proportion of errors involved incorrect halving of tablets (49.1%), followed by omission of a medication (22.0%), extra dose (9.8%), wrong time of administration (8.4%), damaged medication (6.4%), wrong dose (4.2%), and wrong medication (0.2%). These results may underestimate true rates of repackaging errors across long-term care facilities in Germany, as the conditions in the 3 facilities in this study were near-optimal in terms of the environment, process, and quality of repackaging.

Conclusions: Among 48,512 medications inspected over 8 weeks in 3 German long-term care facilities, the rate of repackaging errors was 1.3%, involving 7.3% of daily pill organizers and the medications of 53.00% of residents. The largest proportion of errors involved incorrect halving of tablets.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Drug Packaging / methods
  • Drug Packaging / statistics & numerical data*
  • Female
  • Germany
  • Homes for the Aged / organization & administration*
  • Humans
  • Long-Term Care / organization & administration*
  • Male
  • Medication Errors / classification*
  • Medication Errors / statistics & numerical data
  • Prospective Studies
  • Quality of Health Care
  • Residential Facilities
  • Tablets


  • Tablets