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

James, Kirsty; Barlow, D.; McArtney, Rowena; Hiom, Sarah; Roberts, Dawn E.; Whittlesea, Cate

doi:10.1211/ijpp.17.1.0004

Cited by 183 publications

(146 citation statements)

References 45 publications

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“…Medication errors can occur during any of the three steps of the medication use process: from prescription, medication delivery to dispensing to the patient. Reviews on medication errors [2-10], prescription errors [11] or dispensing errors [12] are numerous. The evaluation and improvement of drug administration process are key elements in patient safety.…”

Section: Introductionmentioning

confidence: 99%

Evaluation of drug administration errors in a teaching hospital

Berdot

Sabatier

Gillaizeau

et al. 2012

BMC Health Serv Res

112

113

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BackgroundMedication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors.MethodsProspective study based on disguised observation technique in four wards in a teaching hospital in Paris, France (800 beds). A pharmacist accompanied nurses and witnessed the preparation and administration of drugs to all patients during the three drug rounds on each of six days per ward. Main outcomes were number, type and clinical importance of errors and associated risk factors. Drug administration error rate was calculated with and without wrong time errors. Relationship between the occurrence of errors and potential risk factors were investigated using logistic regression models with random effects.ResultsTwenty-eight nurses caring for 108 patients were observed. Among 1501 opportunities for error, 415 administrations (430 errors) with one or more errors were detected (27.6%). There were 312 wrong time errors, ten simultaneously with another type of error, resulting in an error rate without wrong time error of 7.5% (113/1501). The most frequently administered drugs were the cardiovascular drugs (425/1501, 28.3%). The highest risks of error in a drug administration were for dermatological drugs. No potentially life-threatening errors were witnessed and 6% of errors were classified as having a serious or significant impact on patients (mainly omission). In multivariate analysis, the occurrence of errors was associated with drug administration route, drug classification (ATC) and the number of patient under the nurse's care.ConclusionMedication administration errors are frequent. The identification of its determinants helps to undertake designed interventions.

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Section: Introductionmentioning

confidence: 99%

Evaluation of drug administration errors in a teaching hospital

Berdot

Sabatier

Gillaizeau

et al. 2012

BMC Health Serv Res

112

113

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“…[18] Other DE could be errors of omission or commission. [19] Effective risk management of DE requires a reporting culture. Medication errors are a leading cause of mortality in the US.…”

Section: Dispensing Errorsmentioning

confidence: 99%

Dispensing errors and uncertainty: Perspectives of pharmacists in a tertiary health facility in Lagos, Nigeria

Anyika

Omosebi

2015

JHA

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Introduction: Dispensing errors (DE) and health care uncertainty impact on health outcomes in a variety of ways. The aim of initiating therapy is to enhance patient wellness but human error probabilities sometimes cause harm or even fatalities and litigations. Objective: The aims of this study are to discuss the underlying factors in dispensing errors, health care uncertainty and therapeutic outcomes, and to identify the extent of human-and system-based sources of errors by exploring hospital pharmacists' attitudes and dispositions to DE and uncertainties; and the implications for patient safety in a tertiary hospital. Methods: The study involved a sample of 44 pharmacists who were administered a survey research inventory designed to assess pharmacists' attitudes and involvement in DE and uncertainty on a variety of important dimensions. Results: Overall the survey research data showed high rating of five human-based dimensions that would minimize dispensing errors, two human-system based, while three system-based (structural) issues were rated as dimensions that would aggravate DE in uncertain health care scenarios. Conclusions: The practical importance of the results for pharmacy practice and therapeutic outcomes are discussed and some suggestions made on how to minimize DE and uncertainty and the policy implications in the hospital pharmacy setting.

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“…In trials, it is important to evaluate the extent of adherence to the protocol in terms of medication dispensing. The most common medication dispensing errors reported in the literature are wrong drugs, strength, form or quantity, as well as wrong labels [2]. Examples and detailed discussion about these issues can be found in the literature [3, 4].…”

Section: Introductionmentioning

confidence: 99%

Assessing protocol adherence in a clinical trial with ordered treatment regimens: Quantifying the pragmatic, randomized optimal platelet and plasma ratios (PROPPR) trial experience

Zhu

Fox

Baraniuk

et al. 2016

Injury

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Background Medication dispensing errors are common in clinical trials, and have a significant impact on the quality and validity of a trial. Therefore, the definition, calculation and evaluation of such errors are important for supporting a trial’s conclusions. A variety of medication dispensing errors can occur. In this paper, we focus on errors in trials where the intervention includes multiple therapies that must be given in a pre-specified order that varies across treatment arms and varies in duration. Methods The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial was a Phase III multi-site, randomized trial to compare the effectiveness and safety of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with a 1:1:2 ratio. In this trial, these three types of blood products were to be transfused in a pre-defined order that differed by treatment arm. In this paper, we present approaches from the PROPPR trial that we used to define and calculate the occurrence of out of order blood transfusion errors. We applied the proposed method to calculate protocol adherence to the specified order of transfusion in each treatment arm. Results Using our proposed method, protocol adherence was greater in the 1:1:1 group than in the 1:1:2 group (96% vs 93%) (p<0.0001), although out of order transfusion errors in both groups were low. Final transfusion ratios of plasma to platelets to red blood cells for the 1:1:1 ratio group was 0.93:1.32:1, while the transfusion ratio for the 1:1:2 ratio group was 0.48:0.48:1. Conclusions Overall, PROPPR adherence to blood transfusion order pre-specified in the protocol was high, and the required order of transfusions for the 1:1:2 group was more difficult to achieve. The approaches proposed in this manuscript were useful in evaluating the PROPPR adherence and are potentially useful for other trials where a specific treatment orders with varying durations must be maintained.

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

Cited by 183 publications

References 45 publications

Evaluation of drug administration errors in a teaching hospital

Evaluation of drug administration errors in a teaching hospital

Dispensing errors and uncertainty: Perspectives of pharmacists in a tertiary health facility in Lagos, Nigeria

Assessing protocol adherence in a clinical trial with ordered treatment regimens: Quantifying the pragmatic, randomized optimal platelet and plasma ratios (PROPPR) trial experience

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