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Dealing with dispensing errors

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The Pharmaceutical Journal Vol 264 No 7096p724
May 13, 2000 Broad Spectrum

Dealing with dispensing errors

By Anthony Cox and John Marriott

The recent case of the death of a child following a dispensing error highlights the real danger medication errors pose to patients. It is estimated that in the United States deaths due to medication errors exceed those due to motor vehicle accidents. Furthermore, it has been suggested that up to 4 per cent of hospital inpatients will experience an adverse event resulting from a medication error related to prescribing, dispensing, or administration events.1
Medication errors cause distress and suffering to patients and ultimately a loss of faith in the health care system, undermining future relationships with health professionals. Pharmacy staff involved in dispensing errors are often traumatised and worried about potential or actual harm caused to a patient.
What is known about the risks associated with dispensing and how can such risks be controlled? In the United Kingdom little research has been performed in the community sector. In four pharmacies monitored in Glasgow, an internal error rate of 50 errors in 5,004 prescriptions was identified (1.00 per cent).2 Nine of these errors (0.18 per cent of the total) were considered to be serious with the potential to require significant medical intervention. However, none of the potentially fatal errors left the pharmacy. In this study, most recorded errors were related to dispensing the wrong medicine or strength of medicine (72 per cent). Incorrect labelling accounted for 14 per cent of errors. The study did also, however, highlight positive findings, in that the pharmacists did detect 20 queries (0.4 per cent) in the sample of prescriptions which required intervention to prevent serious prescribing errors reaching the patient.
More is known about dispensing risks in secondary care. The undetected error rate in hospital is reported as being between 16 and 18 items per 100,000 dispensed items.3,4 Moreover, it has been calculated that a hospital pharmacist makes one error that leaves a pharmacy department every nine months.4
Poor illumination has been associated with dispensing errors. However, many of the reasons for dispensing errors remain anecdotal. Noise, distractions, poor packaging and workload have all been put forward as causes of errors. Kistner and co-workers5 found no correlation between the number of prescriptions dispensed per hour and the total number of errors made, although error peaks were noted during the lunch hour and in the hour before closing. It has also been shown that hospital pharmacies without an independent check on pharmacist dispensing have a statistically significant higher rate of errors than those hospital pharmacy departments with a second check on all work.3
In an Australian survey of pharmacists' attitudes towards dispensing errors, high prescription volumes, pharmacist fatigue, pharmacist overwork, interruptions to dispensing, and similar or confusing drug names were put forward as the principal contributing factors to dispensing errors.6 Fifty-eight per cent of pharmacists stated that there should be a regulatory guideline for the safe dispensing load in Australia.
In a recent article, Reason, a leading expert on human error, described the two models of human error: the person and the system approach.7 Historically, dispensing errors have been dealt with by the person approach, which focuses on the errors of individuals viewed as "free agents capable of choosing safe and unsafe modes of behaviour". Blaming an individual's forgetfulness or inattention is also emotionally satisfying. In addition, separating an individual person's error from any institutional responsibility also appeals to some managers and is legally convenient.

System approach

Focusing on an individual isolates the dispensing error from the dispensing processes in use. A system approach of dealing with errors places emphasis on the working conditions and builds defences that avert errors or mitigate their effect. Many errors are blameless and effective risk management requires a reporting culture. These errors, mishaps and near misses allow recurrent error traps to be uncovered.
Many hospitals run in-house schemes to monitor all external errors as recommended by Spencer and Smith4 and some supply these data to external benchmarking schemes. Others also perform routine monitoring of errors that do not leave the department, or short audits of internal error rates. Such schemes can provide valuable local information that is essential if risk is to be effectively managed. Many hospitals are now setting up or running multidisciplinary "no-blame" error reporting systems and pharmacists should take a lead role in this area.
In the community environment, the development of error reporting is less widely embraced, but some corporate bodies are piloting or using schemes to manage risk similar to those used in secondary care. Individual pharmacists can reflect on their own practice, but their base of knowledge is limited by the size of their operation. The bigger the sample of errors the schemes operate on the easier it is to develop themes from dispensing errors, akin to signal generation in spontaneous adverse drug reaction reporting.
For example, a change in packaging by a manufacturer could trigger a group of dispensing errors. In an individual pharmacy the pharmacist in control would only experience a single error in isolation. Across a wider sample of pharmacies multiple errors may highlight problems which can be rectified to prevent future occurrences. Action could be taken such as moving an item to a different area of shelving. A national reporting scheme for dispensing errors could detect even greater numbers of incidents. These findings could be used for implementation of wider safety measures: for example, a number of errors associated with a pack design could lead to changes by the pharmaceutical industry to increase patient safety.
Many pharmacists might feel uneasy reporting a dispensing error to a system run by the Royal Pharmaceutical Society. The profession might be more comfortable with a national multidisciplinary confidential reporting system for medication errors. In the US, the proposed Medical Error Reduction Act includes mandatory reporting of medication errors. In the UK, no such plans exist at the moment.
The Committee on Safety of Medicines yellow card scheme for adverse drug reactions is a model for a medication error reporting system. It has a proven and hard-earned record as a confidential system. Information could be provided to health professionals in a similar format to Current Problems in Pharmacovigilance. By changing the way we deal with dispensing errors we, as a profession, can save lives.

Anthony Cox is teacher-practitioner at Aston university and City Hospital NHS trust, Birmingham, and ADR pharmacist at the West Midlands Committee of Safety of Medicines regional monitoring centre. John Marriott is senior lecturer in pharmacy practice at Aston university, Birmingham


1.Ferner RE, Aronson JK. Medication errors, worse than a crime. Lancet 2000;355:947-8.
2.Kayne S. Negligence and the pharmacist: (3) dispensing and prescribing errors. Pharm J 1996;257:32-5.
3.Spencer MG, Smith AP. A multicentre study of dispensing errors in British hospitals. Int J Pharm Pract 1993;2:142-6.
4.Bower AC. Dispensing error rates in hospital pharmacy. Pharm J 1990: R22-3.
5.Kistner UA, Keith MR, Sergeant KA et al. Accuracy of dispensing in a high volume, hospital-based outpatient pharmacy. Am J Hosp Pharm 1994;51:2793-7.
6.Peterson GM, Wu MSH, Bergin JK. Pharmacists' attitudes towards dispensing errors: their causes and prevention. J Clin Pharm Ther 1999;24:57-71.
7.Reason J. Human error: models and management. BMJ 2000;320:768-70.

Citation: The Pharmaceutical Journal URI: 20001443

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