A study of unprevented dispensing incidents in Welsh NHS hospitals

Abstract

Objective To monitor unprevented dispensing incidents in NHS hospitals by identifying incident types, drugs involved and factors that may have contributed to the occurrence of incidents. Setting All 20 Welsh NHS hospitals (15 district general; 2 teaching; 2 psychiatric and 1 other specialist hospital). Method Unprevented dispensing incidents that occurred between January 2003 and December 2004 were reported and analysed using a validated method. Incident rate was calculated for those hospitals that provided both incident and issue data. Incident rate was compared with previous research using a two‐sample t‐test. Reported incident types and contributory factors were compared with previous research using chi‐square analysis. Key findings A total of 1005 unprevented dispensing incidents were reported by 20 hospitals. The overall incident rate, based on data from 17 hospitals, was 16 incidents per 100000 items dispensed (range 0.2–46 incidents per 100000 items dispensed). The overall dispensing incident rate was less than previously reported (18 incidents per 100000 items dispensed).This finding was not statistically significant (t = 0.421, P = 0.676). The most common incidents reported were dispensing the wrong strength of drug (n = 241, 24%), wrong drug (n = 168, 17%), wrong form (n = 134, 13%) and printing the wrong warnings/directions on the label (n = 112, 11%). A statistically significant finding was that fewer incidents involving dispensing the wrong drug were reported by Welsh hospitals (17%) compared to previous research in the UK (23%; P = 0.01). Drugs most commonly involved in incidents were insulin (n = 34; 6 incidents per 10000 issues of insulin), nifedipine (n = 16; 10 incidents per 10000 issues of nifedipine) and carbamazepine (n = 10; 5 incidents per 10000 issues of carbamazepine). Conclusion The overall unprevented dispensing incident rate was less than previously reported. Dispensing the wrong strength of the correct drug is a problem. Staff should be aware of the risk of dispensing incidents involving insulin, nifedipine and carbamazepine. Strategies for minimising dispensing incidents include using shelf labels to highlight different strengths or formulations of the same drug, and educating staff about easily confused drugs.

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

“…[1] However, the UK NPSA patient safety taxonomy for unprevented and prevented patient safety incidents was only adopted by four of the reviewed UK papers undertaken after 2004. [44,47,48,72] The World Health Organization is currently developing global patient safety taxonomy. [77,78] Therefore, it is anticipated that the World Health Organization taxonomy will facilitate consistent data collection, sharing of patient safety information and the development of global solutions.…”

“…[3,[33][34][35]43,46,72] Five papers investigated the impact of automation on the types of dispensing errors. [42,[44][45][46][47] Three papers analysed prevented dispensing incidents [42,45,46] and two papers examined unprevented dispensing incidents. [44,47] Adedoye [45] reported that the most common prevented dispensing incidents associated with an automated dispensing system were labelling errors (76%, n = 81) and drug/content errors (18%, n = 20).…”

“…Where ( ) Spencer [3] (n = 178); ( ) James [72] (n = 35); ( ) Roberts [37] (n = 7158); ( ) James [44] postautomation (n = 14); ( ) Roberts [41] (n = 2068); ( ) Beso [43] (n = 32); ( ) James [44] pre-automation (n = 42); ( ) Bower [33] (n = 21); ( ) James [47] (n = 1005); ( ) Barker [39] (n = 208).…”

Factors influencing pharmacist performance: A review of the peer-reviewed literature

“…Of the identified studies, the majority were published in either the USA (n = 15) [43][44][45][46][47][54][55][56]58,59,61,[64][65][66]70], or the UK (n = 14) [37,41,42,[48][49][50]52,53,60,68,69,[71][72][73]. Two studies were conducted in Canada [38][39][40], two in Australia [62,63] and two in Europe [57,67].…”

Evaluating the Impact of Drug Dispensing Systems on the Safety and Efficiency in a Singapore Outpatient Pharmacy

“…Dispensing errors are sub-divided into unprevented and prevented dispensing incidents. Unprevented dispensing incidents (errors) are "dispensing errors detected and reported after medication has left the pharmacy, which may or may not lead to patient harm 1,2 ". Prevented dispensing incidents (near-misses) are "dispensing errors detected during dispensing before the medication has left the pharmacy [1][2][3] ".…”