Preventing medication errors in community pharmacy: frequency and seriousness of medication errors

Abstract

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.

Pharmacists perceptions of community pharmacy practice in UAE: An Overview

“…Unlike results of a study [19] in Denmark which reported only 2% of pharmacists don't know patient details before dispensing. This result showed the wide spread of not knowing the patient before dispensing the medications as it increases the chance of having a drug related problem such as giving inappropriate dose the patient.…”

Incidence, type and causes of dispensing errors: a review of the literature

“…[39] Dispensing error rate Forty-five reviewed papers reported the dispensing error rate in community and/or hospital pharmacy (Tables 7 and 8). [14,15,17,19,21,[24][25][26][27][28]30,32], [3,[33][34][35]38,39,[43][44][45][46][47][49][50][51][52][53][54][55][56][57][59][60][61][62][63][64][65][66][67][68][69][70][71][72] However, only 18% (n = 8) of these papers clearly defined the calculation of dispensing-error rate. [15,28,…”

“…[32] Error types in the UK Five reviewed papers investigated the types of dispensing error in UK community pharmacies. [14,15,[17][18][19] All five papers reported the types of unprevented dispensing incidents but two papers [15,17] also recorded the types of prevented dispensing incidents.…”

“…Any unintentional deviation from professional or regulatory references or guidelines affecting dispensing procedures.' [19] Classification of error types Various categories were employed by the identified research papers (66%, n = 39) to classify the different types of dispensing errors occurring in community (Table 5) [15,17,19,21,24,25,[27][28][29][30][31][32] and hospital pharmacy (Table 6). [3,33-37,39,41-44,47-50,52,54,56-61, 63,64,70,71] The most common error categories identified in the research papers were dispensing the wrong drug (100%, n = 39), strength (95%, n = 37), dosage form (77%, n = 30) and quantity (69%, n = 27), and labelling drugs with the wrong directions (77%, n = 30).…”

Errores en las recetas médicas y en la preparación de estas en farmacia de pacientes ambulatorios: El caso del Hospital de Nueva Imperial

“…Se agregan, además, los errores de dispensación, que se definen como la discrepancia entre lo que indica una receta médica y el medicamento dispensado por la farmacia al paciente, o que distribuye a la sala, sobre la base de esta receta, incluyendo la dispensación de un medicamento con inferior calidad farmacéutica o de información 6 . Si este error es detectado antes que los medicamentos lleguen al paciente, se denomina "dispensing near miss"; para el presente estudio se entenderá este último como un error en la preparación de las recetas, pesquisado antes de entregar los medicamentos al paciente 7 .…”