International Journal of Clinical Pharmacy

, Volume 41, Issue 1, pp 237–243 | Cite as

Contributing factors to outpatient pharmacy near miss errors: a Malaysian prospective multi-center study

  • Retha Rajah
  • Atisha A. Hanif
  • Sherene S. A. Tan
  • Phin Phin Lim
  • Sarah A. Karim
  • Ezazaya Othman
  • Tsyr Fen TeohEmail author
Research Article


Background Detecting errors before medication dispensed or ‘near misses’ is a crucial step to combat the incidence of dispensing error. Despite this, no published evidence available in Malaysia relating to these issues. Objective To determine the incidence of medication labeling and filling errors, frequency of each type of the errors and frequency of the contributing factors at the final stage before dispensing. Setting Six Penang public funded hospitals outpatient pharmacies. Methods A prospective multicentre study, over 8 week’s period. Pharmacists identified and recorded the details of either medication labeling and/or filling error at the final stage of counter-checking before dispensing. Besides, the contributing factors for each error were determined and recorded in data collection form. Descriptive analysis was used to explain the study data. Main outcome measure The incidence of near misses. Results A total of 187 errors (near misses) detected, with 59.4% (n = 111) were medication filling errors and 40.6% (n = 76) were labeling errors. Wrong drug (n = 44, 39.6%) was identified as the highest type of filling errors while incorrect dose (n = 34, 44.7%) was identified as the highest type of labeling errors. Distracted and interrupted work environment was reported to lead the highest labeling and filling errors, followed by lack of knowledge and skills for filling errors and high workload for labeling errors. Conclusion The occurrence of near misses related to medication filling and labelling errors is substantial at outpatient pharmacy in Penang public funded hospitals. Further research is warranted to evaluate the intervention strategies needed to reduce the near misses.


Contributing factors Filling Labeling Malaysia Medication Medication errors Near misses 



We would like to thank the Director of Health Malaysia for permission to publish this research. We also would like to extend our heartiest appreciation to Director of Pharmacy (Penang), Pn.Zubaidah Che Embi and the head of the pharmacy of all the public-funded hospitals involved for their cooperation. Further, we want to acknowledge all the data collectors and staffs of the outpatient pharmacy.


The authors received no financial support for the research, authorship, and/or publication of this article.

Conflicts of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


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Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Pharmacy DepartmentHospital Seberang JayaPeraiMalaysia
  2. 2.Discipline of Social and Administrative Pharmacy, School of Pharmaceutical SciencesUniversiti Sains MalaysiaGelugorMalaysia
  3. 3.Pharmacy DepartmentHospital Pulau PinangGeorge TownMalaysia
  4. 4.Pharmacy DepartmentHospital Kepala BatasKepala BatasMalaysia
  5. 5.Pharmacy DepartmentHospital Sultan IsmailJohor BahruMalaysia

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