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Pharmacy World and Science

, Volume 27, Issue 3, pp 182–190 | Cite as

The Frequency and Potential Causes of Dispensing Errors in a Hospital Pharmacy

  • Adnan Beso
  • Bryony Dean FranklinEmail author
  • Nick Barber
Article

Abstract

Objectives: To determine the frequency and types of dispensing errors identified both at the final check stage and outside of a UK hospital pharmacy, to explore the reasons why they occurred, and to make recommendations for their prevention.

Method: A definition of a dispensing error and a classification system were developed. To study the frequency and types of errors, pharmacy staff recorded details of all errors identified at the final check stage during a two-week period; all errors identified outside of the department and reported during a one-year period were also recorded. During a separate six-week period, pharmacy staff making dispensing errors identified at the final check stage were interviewed to explore the causes; the findings were analysed using a model of human error.

Main outcome measures: Percentage of dispensed items for which one or more dispensing errors were identified at the final check stage; percentage for which an error was reported outside of the pharmacy department; the active failures, error producing conditions and latent conditions that result in dispensing errors occurring.

Results: One or more dispensing errors were identified at the final check stage in 2.1% of 4849 dispensed items, and outside of the pharmacy department in 0.02% of 194,584 items. The majority of those identified at the final check stage involved slips in picking products, or mistakes in making assumptions about the products concerned. Factors contributing to the errors included labelling and storage of containers in the dispensary, interruptions and distractions, a culture where errors are seen as being inevitable, and reliance on others to identify and rectify errors.

Conclusion: Dispensing errors occur in about 2% of all dispensed items. About 1 in 100 of these is missed by the final check. The impact on dispensing errors of developments such as automated dispensing systems should be evaluated.

Keywords

Dispensing errors Medication errors Hospital pharmacy United Kingdom 

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References

  1. Dean, B. 2002Learning from prescribing errorsQual Safety Health Care1125860CrossRefGoogle Scholar
  2. Kaushal, R, Bates, DW. 2002Information technology and medication safety: what is the benefit?Qual Safety Health Care112615CrossRefGoogle Scholar
  3. Rutter, PM, Brown, D, Portlock, JC. 2001Can automated dispensing decrease prescription turn-around time and alter staff work patterns? [abstract]Int J of Pharm Prac9R22Google Scholar
  4. Martin, P. 2002Automated dispensing could be the way forward for your departmentMed Manage1157Google Scholar
  5. Slee, A, Farrar, K, Hughes, D. 2002Implementing an automated dispensing systemPharm J2684378Google Scholar
  6. Allan, EL, Barker, KN, Malloy, MJ, Heller, WM. 1995Dispensing errors and counseling in community practiceAm Pharm NS352532Google Scholar
  7. Flynn, EA, Barker, KN, Carnahan, BJ. 2003National observational study of prescription dispensing accuracy and safety in 50 pharmaciesJ Am Pharm Assoc43191200CrossRefGoogle Scholar
  8. Kistner, UA, Keith, MR, Sergeant, KA, Hokanson, JA. 1994Accuracy of dispensing in a high-volume, hospital-based outpatient pharmacyAm J Hosp Pharm5127937PubMedGoogle Scholar
  9. Guernsey, BG, Ingrim, NB, Hokanson, JA, Doutre, WH, Bryant, SG, Blair, CW. 1983Pharmacists’ dispensing accuracy in a high-volume outpatient pharmacy service: focus on risk managementDrug Intell Clin Pharm177426PubMedGoogle Scholar
  10. Buchanan, TL, Barker, KN, Gibson, JT, Jiang, BC, Pearson, RE. 1991Illumination and errors in dispensingAm J Hosp Pharm48213745PubMedGoogle Scholar
  11. Kistner, UA, Keith, MR, Sergeant, KA, Hokanson, JA. 1994Accuracy of dispensing in a high-volume, hospital-based outpatient pharmacyAm J Hosp Pharm5127937PubMedGoogle Scholar
  12. Allan Flynn, E, Barker, KN, Gibson, JT, Pearson, RE, Berger, BA, Smith, LA. 1999Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacyAm J Health Syst Pharm56131925Google Scholar
  13. BallMJ Douglas, JV. 2003Redefining and improving patient safetyMeth Inf Med412716Google Scholar
  14. Mack, CJ, Kuc, S, Grunewald, RA. 2000Errors in pescribing, dispensing and administration of carbamazepine: a case report and analysisPharm J2657568Google Scholar
  15. Anonymous.2003Boots pharmacist and trainee cleared of baby’s manslaughter, but fined for dispensing a defective medicinePharm J2643902Google Scholar
  16. Noott, A, Phipps, GC. 2003Monitoring and preliminary analysis of internal dispensing errors within a hospital trust [abstract]Pharm World Sci25A42A43Google Scholar
  17. Barker, S. 2003Dispensing errors: recording, analysis and human errorPharm Manage19116Google Scholar
  18. Spencer, MG, Smith, AP. 1993A multicentre study of dispensing errors in British hospitalsInt J Pharm Prac21426Google Scholar
  19. Roberts, DE, Spencer, MG, Burfield, R, Bowden, S. 2002An analysis of dispensing errors in NHS hospitals [abstract]Int J Pharm Pract10R6Google Scholar
  20. Reason, J. 1990Human ErrorUniversity of CambridgeCambridgeISBN 0521314194Google Scholar
  21. Dean, B, Schachter, M, Vincent, C, Barber, N. 2002Causes of prescribing errors in hospital inpatients: a prospective studyLancet35913738CrossRefPubMedGoogle Scholar
  22. Allan, EL, Barker, KN. 1990Fundamentals of medication error researchAm J Hosp Pharm4755571PubMedGoogle Scholar
  23. Cohen, MR. eds. 1999Medication errorsAmerican Pharmaceutical AssociationWashingtonISBN 0917330897Google Scholar
  24. Bower, AC. 1990Dispensing error rates in hospital pharmacy [abstract]Pharm J244R22R23Google Scholar
  25. Ness, JE, Sullivan, SD, Stergachis, A. 1994Accuracy of technicians and pharmacists in identifying dispensing errorsAm J Health Syst Pharm513547Google Scholar
  26. Bond, CA, Raehl, CL. 2001Pharmacists’ assessment of dispensing errors: risk factors, practice sites, professional functions and satisfactionPharmacotherapy2161426CrossRefPubMedGoogle Scholar
  27. Facchinetti, NJ, Campbell, GM, Jones, DP. 1999Evaluating dispensing error detection rates in a hospital pharmacyMed Care373943CrossRefPubMedGoogle Scholar
  28. Betz, RP, Levy, HB. 1985An interdisciplinary method of classifying and monitoring medication errorsAm J Hosp Pharm42172432PubMedGoogle Scholar
  29. Peterson, GM, Wu, MSH, Bergin, JK. 1999Pharmacists’ attitudes towards dispensing errors: their causes and preventionJ Clin Pharm Ther245771CrossRefPubMedGoogle Scholar
  30. Caamano, F, Ruano, A, Figueiras, A, Gestal-Otero, JJ. 2002Data collection methods for analyzing the quality of the dispensing in pharmaciesPharm World Sci2421723CrossRefPubMedGoogle Scholar
  31. Dean, BS, Barber, ND. 1999A validated, reliable method of scoring the severity of medication errorsAm J Health Syst Pharm565762PubMedGoogle Scholar
  32. Mehta, DK. eds. 2004British National Formulary, Volume 47Pharmaceutical PressLondonISBN 0853695849Google Scholar

Copyright information

© Springer 2005

Authors and Affiliations

  • Adnan Beso
    • 1
  • Bryony Dean Franklin
    • 2
    Email author
  • Nick Barber
    • 3
  1. 1.Faculty of PharmacyUniversity of LjubljanaSlovenia
  2. 2.Academic Pharmacy Unit, Hammersmith Hospitals NHS Trust and the School of PharmacyUniversity of LondonUK
  3. 3.The School of PharmacyUniversity of LondonUK

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