Types and Contributing Factors of Dispensing Errors in Hospital Pharmacies

Abstract

Background: Dispensing medication is a chain of multiple stages, and any error during the dispensing process may cause potential or actual risk for the patient. Few research studies have investigated the nature and contributory factors associated with dispensing errors in hospital pharmacies. Aim: To determine the nature and severity of dispensing errors reported in the hospital pharmacies at King Saud Medical City (KSMC) hospital in Saudi Arabia, and at Luton and Dunstable University Hospital (L&D) NHS Foundation Trust in the UK; and to explore the pharmacy staff perceptions of contributory factors to dispensing errors and strategies to reduce these errors. Materials and Methods: A mixed method approach was used and encompassed two phases. Phase I: A retrospective review of dispensing error reports for an 18-month period at the two hospitals. The potential clinical significance of unprevented dispensing errors was assessed. Data was analysed using descriptive statistics in SPSS and A Fisher’s test was used to compare the findings. Phase II: Self-administered qualitative questionnaires (open-ended questions) were distributed to the dispensary teams in KSMC and L&D hospitals. Content analysis was applied to the qualitative data using NVivo qualitative analysis software. Result: Dispensing the wrong medicine or the incorrect strength were the most common dispensing error types in both hospitals. Labelling errors were also common at the L&D pharmacy dispensary. The majority of the unprevented dispensing errors were assessed to have minor or moderate potential harm to patients. Look-alike/sound-alike medicines, high workload, lack of staff experience, fatigue and loss of concentration during work, hurrying through tasks and distraction in the dispensary were the most common contributory factors suggested. Ambiguity of the prescriptions was a specified factor in the L&D pharmacy, while poor pharmacy design and unstructured dispensing process were specified contributory factors in the KSMC pharmacy. Conclusions: Decreasing distractions and enhancing the pharmacy design and the dispensing workflow are necessary to reduce dispensing errors. Furthermore, monitoring and reporting errors and educating the dispensary team about these errors is also needed. Automation and e-prescribing systems may improve dispensing efficiency and safety. The findings of this study reemphasise the fact that dispensing errors are prevalent in hospital pharmacies. Efficient interventions need to be implemented to mitigate these errors.