Development and use of the critical incident technique in evaluating causes of dispensing incidents

Abstract

Aims and objectivesThe study aimed to evaluate the causes of prevented dispensing incidents reported by hospitals using the critical incident technique developed by key-informant interviews, focus group and observation. Setting All Welsh NHS hospitals (n = 20) were invited to participate in the study. Sixteen hospitals agreed to take part; 10 hospitals reported incidents, four hospitals did not report any incidents and two hospitals withdrew from the study. Method In June 2005 three key-informant interviews and a focus group were conducted to determine dispensary workflow, which was then validated by a piloted non-participant observational study at three Welsh hospitals. Self-reported critical incident forms were then developed to collect dispensing-incident data involving drugs at high risk of dispensing incidents. Sixteen Welsh hospitals participated in the 4-month study (January-August 2006). Key findings Dispensary workflow encompassed the following events: prescription receipt, validating patient information, log of prescription, technical check, clinical check, label generation, stock selection, medicines assembly, product labelling, completion of registers, self-checking/endorsing and final accuracy check. Twenty-four incidents were reported by 10 hospitals involving paediatrics (n = 9, 38%), morphine sulphate (n = 5, 21%), insulin (n = 5, 21%), angiotensin-converting enzyme inhibitors (n = 3, 13%) and nifedipine (n = 2, 8%). Incidents commonly occurred at label generation (n = 9, 43%) and stock selection (n = 9, 43%), caused by error-producing conditions, active and latent failures. Active failures involved dispensing the wrong quantity of medication, interchanging different formulations, and computer and stock-selection errors. Error-producing conditions were reported as high workload, complex prescriptions and interruptions. Latent conditions were inadequate staffing/ skill mix, unclear drug computer selection lists and the storage of drugs on dispensary shelves. Conclusion The critical incident technique provided an in-depth understanding of the causes of dispensing incidents. Dispensing incidents arose because of organisational pathologies, error producing conditions and active failures such as inadequate staffing, high workload, interruptions, and computer and drug-selection errors.Patient safety is of major importance to the pharmacy profession and central to this is the minimisation of dispensing incidents. Unprevented dispensing incidents, detected and reported after the medication has left the pharmacy, occur relatively infrequently at a rate of 16-18 per 100000 items dispensed in UK hospitals. [1][2][3][4] In contrast, prevented dispensing incidents identified during the dispensing process before medication has left the pharmacy occur more frequently, at a rate of 0.94-2.1% in UK hospitals. 1,5,6 Despite the low incidence, dispensing incidents, if undetected, can cause serious patient harm, morbidity and occasionally death. 7-9 Thus it is imperative that the dispensing incidents are reviewed so ...

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.…”

“…[23,29] Reason's human error theory was employed in three reviewed papers to understand the aetiology of prevented dispensing incidents in UK hospital pharmacies. [40,43,48] Analysis of staff interviews [40,43] and self-completed critical incident report forms [48] revealed that prevented dispensing incidents were caused by a complex interweaving of active failures (slips, lapses and mistakes), latent conditions and errorproducing conditions. Slips were identified as selecting the wrong drug or strength of medication, lapses involved forgetting to remove inappropriate cautionary labels during label generation, and mistakes involved assumptions that products were interchangeable, doses were the same as previously recorded in patient medication record and dispensing in accordance with labels rather than prescriptions.…”

“…Latent conditions identified were lack of guidance on dealing with interruptions, poor labelling or packaging of medicines and unclear presentation of drug selection lists on computer software used to generate labels. [40,43,48] However, these studies involved the retrospective reporting of the causes of prevented dispensing incidents 24-48 h after the incident occurred. Consequently, the findings are highly subjective and may be biased by failure to divulge or recall details of incident.…”

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

“…Six studies (one reported in two papers) used retrospective reviews of disciplinary/performance records to explore performance [38][39][40]61,62,68,71]. Three studies used retrospective analysis of error data [52,53,72], whilst seven studies used prospective data collection techniques on errors [37,42,56,69,70] or clinical interventions [50,64]. Other less common methods used included critical incident technique [52], simulation testing in hypothetical scenarios [65], review of prescription monitoring incidents [41], analysis of claims data [59], videotaping and review of pharmacist performance [46], a controlled study exploring impact of ambient sounds on errors [47], comparison of error rates at different illumination levels [44], root-cause analysis of transcription errors [57], and a literature review (Table 1) [51].…”

“…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].…”