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Wrong drug strength commonest error when selecting drugs for dispensing

By News team

Lack of attention to drug strengths is behind most drug selection errors in the dispensary, a hospital pharmacy study has concluded.

Confusion between drug names that look or sound alike is not as frequent as previously thought, the findings suggest, with only 31 per cent of drug selection errors linked to this.

Researchers looked at dispensing errors reported over four years at the two main dispensaries of Guy’s and St Thomas’ NHS Foundation Trust in London, and analysed all errors relating to the mis-selection of drugs (see Panel). They found that most drug selection errors (58 per cent) are related to confusion between different strengths of the same drug.

Selection errors are more likely to occur with rarely dispensed drugs, particularly if they have names similar to medicines that are more frequently prescribed.

The researchers found that prescribed and wrongly selected drugs were listed close to one another on dispensary computer systems in 45 per cent of errors, suggesting that pharmacists scroll the drugs list and select specifications similar to those prescribed.

They suggest that the use of enhanced text such as “Tallman” (writing part of a drug’s name in capital letters) or coloured lettering to highlight sections of the drug specification, or using different fields for the drug name, strength and formulation on the computer drugs list, may help prevent errors.

Testing of new error-prevention strategies would be needed to measure whether they really reduce errors, they say.

The study is published in the February issue of the International Journal of Pharmacy Practice (2011;19:51).

Study method

Four years’ worth of data on prevented and unprevented dispensing errors were obtained, and a subset analysed. These included all labelling and content errors relating to drug name, strength and formulation.

Errors relating to the clinical safety or legal validity of prescriptions, the extemporaneous preparation of products or the dispensing of items that are not medicines (eg, dressings) were excluded.

The trust recorded a total of 911 dispensing errors from 2005–08. Nearly a quarter (23.2 per cent; 211) of these involved errors in drug selection, with 122 relating to incorrect drug strength, 65 to incorrect drug name and 24 to incorrect formulation.

Citation: The Pharmaceutical Journal URI: 11067966

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