Background: Medication errors are a widespread problem which can, in the worst case, cause harm to patients. Errors can be corrected if documented and evaluated as a part of quality improvement. The Danish community pharmacies are committed to recording prescription corrections, dispensing errors and dispensing near misses. This study investigated the frequency and seriousness of these errors. Methods: 40 randomly selected Danish community pharmacies collected data for a defined period. The data included four types of written report of incidents, three of which already existed at the pharmacies: prescription correction, dispensing near misses and dispensing errors. Data for the fourth type of report, on adverse drug events, were collected through a web-based reporting system piloted for the project. Results: There were 976 cases of prescription corrections, 229 cases of near misses, 203 cases of dispensing errors and 198 cases of adverse drug events. The error rate was 23/10 000 prescriptions for prescription corrections, 1/10 000 for dispensing errors and 2/10 000 for near misses. The errors that reached the patients were pooled for separate analysis. Most of these errors, and the potentially most serious ones, occurred in the transcription stage of the dispensing process. Conclusion: Prescribing errors were the most frequent type of error reported. Errors that reached the patients were not frequent, but most of them were potentially harmful, and the absolute number of medication errors was high, as provision of medicine is a frequent event in primary care in Denmark. Patient safety could be further improved by optimising the opportunity to learn from the incidents described.

Background: Medication errors can have serious consequences for patients, and medication safety is essential to pharmaceutical care. Insight is needed into the vulnerability of the working process at community pharmacies to identify what causes error incidents, so that the system can be improved to enhance patient safety. Methods: 40 randomly selected Danish community pharmacies collected data on medication errors. Cases that reached patients were analysed, and the most serious cases were selected for root-cause analyses by an interdisciplinary analysis team. Results: 401 cases had reached patients and a substantial number of them had possible clinical significance. Most of these errors were made in the transcription stage, and the most serious were errors in strength and dosage. The analysis team identified four root causes: handwritten prescriptions; ''traps'' such as similarities in packaging or names, or strength and dosage stated in misleading ways; lack of effective control of prescription label and medicine; and lack of concentration caused by interruptions. Conclusion: A substantial number of the medication errors identified at pharmacies that reach patients have possible clinical significance. Root-cause analysis shows potential for identifying the underlying causes of the incidents and for providing a basis for action to improve patient safety.

Research dealing with governmental and managerial ideals and tools for transparency has observed how these tools co-create new types of blindness. It has documented the existence of three different types of blindness: blindness caused by power games, by cognitive limitations and blindness as a side effect of the categories applied. This paper puts forward a fourth type of organizational blindness in addition to the already documented ones, namely self-imposed blindness to potentially destructive information. This paper studies how relevant -but problematic -information is actively ignored and kept out of sight in the decision processes by looking at a specific case study involving the construction of a model intended to control, and render transparent, the quality of health services in Denmark. This paper outlines the forms of inattentiveness which make communication blind to information that could question the quality model. Five forms of inattentiveness are identified that function as answers to the question of how communication avoids actualizing relevant but also potentially destructive information. This study documents a considerable amount of blindness to potentially relevant themes and it points to activities that produce this blindness as they reduce the probability that potentially destructive subjects are actualized. Information is not only something organizations need, but may also be something they protect themselves against. In that case, the forms of inattentiveness may be a function that forms organizational processes.

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