Medication errors in community pharmacy: an investigation into the types and potential causes

Abstract

Objectives To establish the nature of medication errors occurring within community pharmacy and analyse common error patterns. To identify factors which influence the occurrence of medication errors and near misses, with the intention of designing systems or strategies to reduce the occurrence of these events. Setting Fifteen community pharmacies situated within Brighton and Hove City Primary Care Trust, East Sussex, between January and March 2004. Method A self-reporting form was designed, piloted and administered to pharmacists, which gathered information on the detection of an error or near miss in the dispensing process. Key findings One-hundred and thirteen near misses and thirty-two medication errors were reported. The majority of near misses were detected by the pharmacist at the final check, and the majority of medication errors were detected by the patient or patient's representative. Selection errors were most common, with similar drug names and packaging cited as the main contributory factors. 'Business' was frequently cited as the circumstance surrounding the error. Conclusion This study demonstrates that pharmacists do have an important part to play and the positive impact of community pharmacists in preventing, detecting and correcting errors and thus preventing harm to patients in the primary care setting. However, medication errors do occur, and therefore a multifactorial approach by manufacturers, marketing and packaging personnel, in addition to input from pharmacists, may be an effective permanent solution in reducing the errors made.Rigorous clinical trials prove medicines to be therapeutically effective treatments. However, with an increasing range of medicines available for each therapeutic area, complicated drug regimens and an ageing population becoming reliant on more than just one drug for a variety of conditions, the risk for interactions and scope for human error is increased. Many medication errors display strong similarities to incidents that have occurred on previous occasions, and in some cases replicate them.

Workload in community pharmacies in the UK and its impact on patient safety and pharmacists’ well-being: a review of the evidence

“…These findings were slightly at odds with results from a study involving 15 pharmacies in one Primary Care Trust looking at causes of medication errors during a 3‐month period (Lynskey et al. 2007).…”

“…2005b, Chen et al. 2005, Lynskey et al. 2007), while three studies used non‐participant observation work sampling techniques (Savage 1995, 1997, Rutter et al.…”

Safety of medication use in primary care

“…These attributes underpin medication safety concepts such as error reporting and learning, and the development and implementation of prevention strategies, as errors are often the results of the systems that produce them [21]. A few studies have estimated the preventability of medication errors in primary care [22–30]. In the UK, approximately 5% admissions to secondary care have taken their roots from preventable drug‐related problems at an estimated cost of over £750 million per year to the NHS [7].…”

Exploring the relationship between safety culture and reported dispensing errors in a large sample of Swedish community pharmacies

“…In community pharmacies, these errors are present in a frequency varying between 0.01% [1,2] and 22% [3], depending on the definition of dispensing errors and the method used to assess these errors. Types of errors include selection errors such as improper choice of medicines, dosage forms, strengths or quantities, as well as erroneous dosage instructions [1,2,4-7]. The causes of dispensing errors vary but commonly noted causes are look-alike packages and similar brand names [1,8].…”