Preventing dispensing errors by alerting for drug confusions in the pharmacy information system—A survey of users

Abstract

IntroductionDrug confusion is thought to be the most common type of dispensing error. Several strategies can be implemented to reduce the risk of medication errors. One of these are alerts in the pharmacy information system.ObjectiveTo evaluate the experiences of pharmacists and pharmacy technicians with alerts for drug name and strength confusion.MethodsIn May 2017, a cross-sectional survey of pharmacists and pharmacy technicians was performed in community pharmacies in the Netherlands using an online questionnaire.ResultsOf the 269 respondents, 86% (n = 230) had noticed the alert for drug name confusion, and 26% (n = 67) for drug strength confusion. Of those 230, 9% (n = 20) had experienced that the alert had prevented dispensing the wrong drug. For drug strength confusion, this proportion was 12% (n = 8). Respondents preferred to have an alert for drug name and strength confusion in the pharmacy information system. ‘Alert fatigue’ was an important issue, so alerts should only be introduced for frequent confusions or confusions with serious consequences.ConclusionPharmacists and pharmacy technicians were positive about having alerts for drug confusions in their pharmacy information system and experienced that alerts contributed to the prevention of dispensing errors. To prevent alert fatigue, it was considered important not to include all possible confusions as a new alert: the potential contribution to the prevention of drug confusion should be weighed against the risk of alert fatigue.

The Use of a Decision Support System in Swedish Pharmacies to Identify Potential Drug-Related Problems—Effects of a National Intervention Focused on Reviewing Elderly Patients’ Prescriptions

“…A pharmacy dispensing information system is a system used at pharmacies for processing and dispensing prescriptions, but systems differ in functionality and design. One way of supporting pharmacists in detecting potentially inappropriate prescriptions or avoiding dispensing errors are CDSSs that may be integrated in the pharmacy information system or provided in another manner [ 13 , 21 , 22 , 23 , 24 ].…”

Dispensing errors in Lebanese community pharmacies: incidence, types, underlying causes, and associated factors

“…It also highlights the need to add an alert system to the pharmacy dispensing software that would warn the pharmacist about possible confusion when dispensing look or sound alike medicines. 34 …”

Fatores associados a erros de dispensação de medicamentos: contribuição à melhoria de sistemas de medicação

“…Os fatores mais comuns encontrados em outras pesquisas foram: alta carga de trabalho, baixo número de funcionários, confusão com nomes e sons parecidos/similares, falta de conhecimento/experiência da equipe da farmácia, pressa e interrupções/distrações. Entretanto, estes fatores foram apontados a partir de relatos subjetivos, entrevistas e/ou formulários de notificação de incidentes [13][14][15][16][17][18] .…”