An analysis of dispensing errors in NHS hospitals

Roberts, Dawn E.; Spencer, Michael G.; Burfield, Robin; Bowden, Steve

doi:10.1111/j.2042-7174.2002.tb00664.x

Cited by 24 publications

(55 citation statements)

References 1 publication

(2 reference statements)

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“…The most commonly reported dispensing error was dispensing wrong drug. Previous studies have reported dispensing wrong drugs in all types of inpatient settings [25,[32][33][34][35]. Omission due to drug unavailability was also a common error identified.…”

Section: Discussionmentioning

confidence: 94%

Drug-related problems and their clinical interventions in a Ghanaian teaching hospital

2016

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Background: Errors occur frequently in the use of medicines. Pharmacists play a key role in error identification and make appropriate interventions as they work with other healthcare professionals. These error recovery roles of pharmacists contribute to patient safety. This study was to evaluate the clinical interventions made to drug-related problems at a tertiary care setting. Method: This involved a retrospective review of clinical intervention reports submitted by pharmacists working over the period January 2011 to December 2013. Results: The 24 pharmacists submitted 529 handwritten reports; of these, 448 reports had complete data. The most frequently reported drugs with error were warfarin (9.5%), potassium chloride (6.0%) and potassium citrate (5.5%). The pharmacists made 1019 clinical interventions and recommendations. The average intervention per report was 2.5 (S.D ± 0.67). The interventions and recommendations made were categorised as drug regimen change (76.1%), monitoring required (13.0%), communication (5.4%), counselling required (5.0%) and adverse drug reporting (0.6%). Majority (90.5%) of the recommendations and interventions made by pharmacists were accepted and implemented. Monitoring-required based interventions were significantly more likely to be accepted (130 vs 38; p <0.0001). Conclusion: Pharmacists played a role in drug error recovery and prevented medication errors from reaching patients. These error mitigation efforts of pharmacists can serve as a priority in patient safety strategy.

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Section: Discussionmentioning

confidence: 94%

Drug-related problems and their clinical interventions in a Ghanaian teaching hospital

2016

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“…[3,33,37,39,41,43,44,47,72] In contrast, labelling medicines with the wrong directions, dispensing the wrong drug and strength were the most common prevented dispensing incidents in hospitals with manual and automated dispensing systems (Figure 6). [3,[33][34][35]43,46,72] Five papers investigated the impact of automation on the types of dispensing errors.…”

Section: Incidence In Brazilmentioning

confidence: 99%

“…O t h e r Figure 5 Most common types of unprevented dispensing incidents reported by UK hospital pharmacies with manual [3,33,37,39,41,43,44,47,72] and automated [44,47,72] dispensing systems. 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).…”

Section: Error Types In the Usmentioning

confidence: 99%

“…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).…”

Section: Error Types In the Usmentioning

confidence: 99%

“…[70] Error types in the UK Fourteen papers investigated the types of dispensing error occurring in UK hospitals. [3,[33][34][35]37,39,[41][42][43][44][45][46][47]72] Five papers investigated unprevented dispensing incidents, [37,39,41,44,47] five papers explored prevented dispensing incidents [34,35,42,45,46] and four papers researched both unprevented and prevented dispensing incidents. [3,33,43,72] The most common types of unprevented dispensing incidents in hospitals with both manual and automated dispensing systems were supplying the wrong …”

Section: Incidence In Brazilmentioning

confidence: 99%

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

James¹,

Barlow²,

McArtney³

et al. 2009

International Journal of Pharmacy Practice

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Objectives To identify, review and evaluate the published literature on the incidence, type and causes of dispensing errors in community and hospital pharmacy. Method Electronic databases were searched from 1966 to February 2008. This was supplemented by hand-searching the bibliographies of retrieved articles. Analysis of the findings explored the research methods, operational definitions, incidence, type and causes of dispensing errors. Key findings Sixty papers were identified investigating dispensing errors in the UK, US, Australia, Spain and Brazil. In general, the incidence of dispensing errors varied depending on the study setting, dispensing system, research method and operational definitions. The most common dispensing errors identified by community and hospital pharmacies were dispensing the wrong drug, strength, form or quantity, or labelling medication with the incorrect directions. Factors subjectively reported as contributing to dispensing errors were look-alike, sound-alike drugs, low staffing and computer software. High workload, interruptions, distractions and inadequate lighting were objectively shown to increase the occurrence of dispensing errors. Conclusions Comparison of the reviewed studies was confounded by differences in study setting, research method and operational definitions for dispensing errors, error rate and classification of error types. The World Health Organization is currently developing global patient safety taxonomy. Such a standardized taxonomy for dispensing errors would facilitate consistent data collection and assist the development of error-reduction strategies.

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