Dispensing Errors and Self-medication Practices—Pharmacists’ Experience in Tabuk: A Cross-sectional Study

ABSTRACT

Background:

Community pharmacists are engaged in various professional activities starting from drug dispensing to promoting the well-being of patients. They dispense medications as stated in the prescription and are also licensed to prescribe over-the-counter (OTC) medications. Self-medication is widely practiced in various countries, which may lead to irrational drug use. The objectives of this study were to identify the factors associated with dispensing errors, to find ways to minimize dispensing errors, to identify patients’ reasons for self-medication, and to find the drugs commonly utilized by patients as OTC medications and the sources of their drug information.

Methods:

A cross-sectional survey of a convenience sample of 286 registered community pharmacists all over Tabuk was conducted using a self-administered questionnaire.

Results:

Physician’s unclear handwriting in the prescription was the major factor for dispensing error (2.6 out of 3) and writing the prescription clearly by the physician or using a printed form of prescription was an important factor in minimizing dispensing errors (2.91 out of 3). Previous similar complaints in the past were the main reason for self-medication (2.45 out of 3) with analgesics and antipyretics being the commonly dispensed drug groups dispensed as OTC medications (2.95 out of 3).

Conclusion:

Self-medication practices and dispensing errors are widespread in Tabuk. Antibiotics were dispensed as OTC medication, which may lead to more chance of irrational drug use. Writing the prescription clearly and legibly would reduce dispensing errors. It is the community pharmacists’ responsibility to increase awareness regarding the appropriate use of drugs to the public.

INTRODUCTION

The role of community pharmacists in many countries has expanded in recent years. Community pharmacists nowadays are involved in a wide range of activities that concern patient care, starting from drug dispensing and optimization of drug therapy to promoting the health and well-being of patients.[1] Additionally, they play an essential role in providing rational drug information as well as counseling patients regarding the rational use of medications.[2] The core of pharmacy practice is the dispensing of medications, and the main concern in the profession of pharmacy is dispensing errors, which can affect the safety of patients.[3,4] Dispensing error is the mismatch between prescribed medication and dispensed medication,[5] Dispensing errors include dispensing wrong medication, wrong dose, wrong strength, wrong duration, and the dispensing of a drug with poor pharmaceutical quality.[5,6] Dispensing errors are the most common types of medication errors in the developing countries.[7,8,9] In the United Kingdom and the United States, the prevalence of dispensing errors in community pharmacies ranges from 0.04% to 24%.[3] According to a recent Jordanian study, 52.6% of dispensing errors in community pharmacies are moderate and 8.6% are severe.[7] Beyond the patient’s physical harm, the danger of a dispensing error also includes the loss of the patient’s trust in healthcare providers.[10] Many studies have been done to examine the factors that contribute to dispensing errors. According to a study conducted in Saudi Arabia, the two main causes of dispensing errors were dispensing by pharmacy assistants and a high workload. Enhancing doctors’ handwriting and reducing effort could primarily reduce these errors.[11] Poor physician handwriting was the main cause of dispensing errors in Jordan.[12] Moreover, in the United Kingdom, the most common causes of dispensing errors were reading the prescription wrongly and confusion over similar drug names or similar packaging.[13]

Self-care is a common habit that is practiced by many people to stay healthy and treat minor diseases or self-diagnosed disorders.[14] According to the World Health Organization, self-medication is “the selection and use of medicines by individuals to treat self-recognized illnesses or symptoms.”[15] A lot of medications are taken without a physician’s prescription or counseling in developing countries, so self-medication is considered a universal phenomenon.[16] Up to 81.4% of Saudi Arabia’s population reported using medicines without a prescription at some time in their lives.[17] However, there is a difference in the prevalence of self-medication practices between developing and developed countries due to variations in cultural and socioeconomic factors, and differences in healthcare systems, including compensation rules, access to healthcare, and medication dispensing policies.[18] Although the prevalence of self-medication practices varies by nation, the typical factors that affect self-medication include age, gender, income, educational level, medical knowledge, and minor ailments.[19,20] Self-medication has been linked to the failure of the healthcare system, which occurs when there is an imbalance in the distribution of resources for healthcare and an increase in healthcare expenses as a result.[21] Self-medication is frequently obtained via family members, close friends, neighbors, pharmacists, previously prescribed medications, recurrence of disease, and advertisements in popular publications or newspapers.[22,23,24]

Studies have been performed in various countries to assess the practice of self-medication in various study populations. Self-medication practice has resulted in different complaints affecting various parts of the body and organs.[25,26,27,28] Adverse effects, drug interactions, overdose, and other medication-related issues can occur when over-the-counter (OTC) drugs are misused.[29] Such avoidable adverse consequences of irrational self-medication practices must be highlighted to the community and an educational approach toward health education should be followed to reduce it.[30]

The aims of this study were to determine the cause of dispensing errors and ways to reduce the errors, to determine the patients’ self-medication reasons, medications acquired by patients as OTC medications, and the sources of their drug information.

MATERIALS AND METHODS

A cross-sectional survey of a convenience sample of 286 registered community pharmacists all over Tabuk was conducted. Data collection was performed for six months, using a questionnaire, which was self-administered. The Arabic questionnaire was obtained from the author with the permission to use it.[12] The questionnaire was distributed among licensed pharmacists working in community pharmacies in different areas of Tabuk. The responses provided by the community pharmacists were stored anonymously and confidentially. Their consent was obtained. The questionnaire contained different questions about self-medication and dispensing errors. The questionnaire was divided into three sections: section 1 comprised closed-ended questions regarding demographic information such as gender and years of experience; section 2 contained a series of questions of three response alternatives (Never—1, sometimes—2, and always—3) about dispensing errors. Twelve questions to assess about pharmacists’ experience with dispensing errors and 8 questions on the most crucial elements in minimizing these errors; section 3 included three response alternatives (Always-3, sometimes-2, never-1) about self-medication. Eight questions aimed to find the most frequent causes of self-medication, six questions about the drugs used in practice more frequently, four questions to find the patient’s drug information sources, and five questions on the opinions of pharmacists about self-medication consequences. This research was approved by the Local Research Ethics Committee (UT-243-81-2023).

Statistical analysis was done using SPSS software version 22.0. Descriptive statistics (mean, percentage, and standard deviation) were used to represent respondents and their characteristics. The F-test for two samples for variances was used to compare the variance of scores between gender and the causes of dispensing errors and perceived factors to reduce the errors. ANOVA was used to compare the scores of factors associated with dispensing errors and perceived factors associated with reducing dispensing errors based on years of experience. Spearman’s rho test was used to find the correlation between years of experience and factors associated with dispensing errors and perceived factors associated with reducing dispensing errors. P <0.05 was kept as statistically significant.

RESULTS

There were 286 community pharmacists in total who took part in this study. Less than a quarter (18.2%) of the respondents were female. Almost all the female pharmacists had less than 5 years of experience (n = 50, 96.15%) and two female pharmacists had 5–10 years of experience. The majority of participants had 5–10 years of experience in community pharmacies (38.5%), followed by those with more than 10 years of experience (32.2%), and the lowest number had less than 5 years of experience (29.4%). The three response alternatives were expressed as mean (out of 3) and the standard deviation.

The primary role of a community pharmacist is to dispense the medication. Pharmacists should be more alert while dispensing medication, since it involves the life of patients. Table 1 shows the reasons contributing to dispensing errors and indicates that physicians’ unclear handwriting in the prescription was the major factor associated with dispensing errors, followed by increased work pressure, and similar drug names and concentrations.

Table 1.

Factors associated with dispensing errors

Factors	Mean (out of 3)	Standard deviation
Physician’s unclear handwriting	2.6	0.53
Similar drug names and concentrations	2.12	0.68
Similarity of drugs in their labeling and packaging	2.05	0.67
Dispensing medicines by a stressed pharmacist	2.01	0.67
Dispensing medicines by assistant pharmacist	1.86	0.7
Dispensing medicines by pharmacy employees	1.71	0.89
Increased work pressure	2.15	0.6
The pharmacist working alone	2.02	0.74
Pharmacists’ interruptions	1.82	0.59
Lack of time to talk with the patient	1.97	0.55
Lack of privacy to talk with patient	1.92	0.67
The pharmacist’s dissatisfaction with the work environment	1.74	0.62

We assessed the factors associated with dispensing errors based on gender. Based on the P value, we found that none of the factors displayed significant difference between male and female.

The factors associated with dispensing error were compared among the years of experience. It was found that only two factors “lack of time to talk with the patient” and “lack of privacy to talk with the patient” showed a statistically significant P value (0.0003).

According to Table 2, writing the prescription clearly by the physician or using a printed form of prescription was an important factor in reducing dispensing errors.

Table 2.

Perceived factors associated with reducing dispensing errors

Factors	Mean (out of 3)	Standard deviation
Writing the prescription clearly by the physician or using a printed form of prescription	2.91	0.32
Up-to-date knowledge of pharmacists	2.83	0.41
Improving the work environment and reducing pharmacist’s workload	2.86	0.37
Presence of more than one pharmacist in the pharmacy	2.69	0.55
Suitable place and privacy in the pharmacy to talk with the patient	2.58	0.53
Calm work environment	2.61	0.52
Pharmacies complying with laws and legislation	2.84	0.39
Issuing a certificate of practicing the profession	2.72	0.52

With regard to the perceived factors associated with reducing dispensing errors based on gender, various factors like writing the prescription clearly by the physician or using a printed form of prescription, up-to-date knowledge of pharmacists, improving the work environment and reducing pharmacist’s workload, having more than one pharmacist in the pharmacy, and issuing a certificate of practicing the profession showed significant difference among male and female. Female pharmacists perceived all the significant factors except issuing a certificate of practicing the profession.

The perceived factors associated with reducing dispensing errors were analyzed based on years of experience and it was found that a statistically significant difference exists in factors such as the presence of more than one pharmacist in the pharmacy, a calm work environment, and the issuance of a certificate of practicing the profession.

The correlation between years of experience of pharmacists and the reasons for dispensing errors was analyzed. There were four significant weak negative correlations among lack of time to talk with the patient (r = -0.319, P = <0.001), lack of privacy to talk with the patient (r = -0.272, P = 0.001), similar drug names and concentrations (r = -0.166, P = 0.047), and similarity of the drug in their labeling and packaging (r = -0.165, P = 0.049). There was a positive correlation between years of experience and two perceived factors but it was not statistically significant: dispensing of medicines by assistant pharmacist (r = 0.019, P = 0.819), and dispensing by pharmacy employees (r = 0.038, P = 0.653).

The correlation between years of experience of pharmacists against perceived factors associated with reducing dispensing error was assessed. There were two statistically significant weak correlations—one positive and one negative. Increasing years of experience of pharmacists was correlated with a decrease in perceived necessity of the presence of more than one pharmacist in the pharmacy (r = -0.203, P = 0.015). Increasing years of experience of pharmacists was correlated with high perception of the necessity of issuing a certificate of practicing the profession (r = 0.177, P = 0.035).

Another significant medical issue is self-medication, which is widely used by Saudis. The potential causes of patients’ self-medication were found in this study [Table 3], and they included: previous similar complaints, minor ailment, trusting pharmacists and pharmaceutical services, and economic reasons.

Table 3.

Reasons reported by community pharmacists for self-medication

Reasons	Mean (out of 3)	Standard deviation
Previous similar complaints	2.45	0.52
Trusting pharmacists and pharmaceutical services	2.35	0.53
Economic reasons	2.35	0.62
Minor ailment	2.38	0.51
To prevent a specific disease	1.95	0.58
Fear of visiting a physician	2.09	0.58
Lack of time to visit the physician	2.2	0.56
The distance of hospital is too far	1.93	0.7

The perceived reasons for self-medication were compared based on gender. Using medications to prevent a specific disease was the only reason for self-medication, which showed a statistically significant difference between male and female.

The reasons for self-medication as reported by community pharmacists were compared based on pharmacist’s years of experience. Recurrence of disease and previous experience with related medication was the only reason that was found to be statistically significant.

As demonstrated in Table 4, various drug classes were misused and dispensed without prescription, and the most dispensed OTC medications were analgesics and antipyretics. Other dispensed drug groups were anti-cold drugs, anti-cough drugs, and anti-histamine drugs. Antibiotics and sedatives were the least dispensed drugs as OTC medications.

Table 4.

Drug groups dispensed as OTC medications at community pharmacies

Drug groups	Mean (out of 3)	Standard deviation
Antibiotics	1.35	0.6
Analgesics and antipyretics	2.95	0.21
Anti-histamine	2.58	0.54
Anti-cough	2.67	0.49
Anti-cold	2.75	0.43
Sedatives	1.32	0.55

Pharmacists were the main source of drug information for the patients, followed by the internet and social networks. Scientific journals were the least source of drug information for patients [Table 5].

Table 5.

Perceived sources of drug information for patients

Source of drug information	Mean (out of 3)	Standard deviation
Pharmacists	2.49	0.51
Friends and neighbors	2.25	0.49
Scientific journals	1.64	0.64
Internet and social networks	2.41	0.54

According to Table 6, misuse of the drug was the most noticed consequence of self-medication, followed by bad habit in the society.

Table 6.

Experience of community pharmacists toward consequences of self-medication

Consequences of self-medication	Mean (out of 3)	Standard deviation
Misuse of the drug (psychological and physiological habituation)	2.46	0.59
Covering the actual symptoms of the disease	2.36	0.55
Bad habit in society	2.40	0.55
If practiced correctly, increases the patient’s confidence	2.31	0.59

DISCUSSION

This study was conducted to know the community pharmacists’ experience with self-medication practice and dispensing errors. In our study, most of the respondents were male (81.8%) and this is because males prefer to be community pharmacists and females prefer to work in other areas compared to community pharmacies. This finding is different from the study conducted in Jordan, where the majority of study participants were female (72.7%).[12] They reported that this is because most of the pharmacy students were female. According to their study findings, the majority of pharmacists said that the errors associated with dispensing medications are sometimes on the rise. The result of our study showed that physician’s unclear handwriting was the major reason for dispensing errors. This finding was in accordance with another study.[31] Other important contributing factors of dispensing errors were increased work pressure and similar drug names and concentrations. A high workload can affect the communication of pharmacists with patients due to lack of time. This result was supported by other studies.[32,33]

Our findings supported that there was a positive correlation between years of experience and dispensing medicines by assistant pharmacists, which is one of the factors that is associated with dispensing errors, but it was not statistically significant (r = 0.019, P = 0.819). However, there was a statistically significant weak negative correlation among the similarity of the drugs in their labeling and packaging (r = -0.165, P = 0.049). These results were in accordance with other study results.[11]

According to our study findings, writing the prescription clearly by the physician or using a printed form of prescription was an important factor in reducing dispensing errors. This result was consistent with the report of other studies.[11,12] Other factors perceived to reduce dispensing errors include ensuring that pharmacies comply with laws and legislation, lowering the pharmacist’s workload, keeping pharmacists up to date on knowledge, and providing a suitable place in the pharmacy to talk with the patient and maintain his/her privacy. To reduce dispensing errors and pharmacy interruption, the pharmacy must have a better environment and minimize the load on the pharmacist. One of the factors that also played a major role in reducing dispensing errors is rechecking and making sure that the area of dispensing is appropriate in the pharmacy and this is achieved through the presence of more than one pharmacist, which contributes to making the counseling better. Counseling can lower errors since it helps pharmacists to identify the factors responsible for errors and make them dispense proper medications to an appropriate person.[12]

Our results showed that there was a significant positive correlation between years of experience and the importance of issuing a certificate of practicing the profession, which is one of the factors that is associated with reducing dispensing errors (r = 0.177). Increasing years of experience of pharmacists was correlated with a decrease in the perceived necessity of the presence of more than one pharmacist in the pharmacy (r = -0.203). These results were inconsistent with other study results,[11] which reported that increasing years of experience was positively correlated with the perception of legible physician’s handwriting.

Another major medical issue that is prevalent in Tabuk city is self-medication. In our study, the causes of self-medication were determined, and the majority of respondents indicated that the primary factor was having a previous similar disease. This result was in contrast with other studies, which reported that economic factor was the most important reason for self-medication.[34] Patients’ trust in community pharmacists and pharmaceutical services were the common reasons for patients to follow the advice of pharmacists without seeing their doctor. Patients do not have time to wait in the doctor’s clinic, patients’ fright that their diseases will be discovered if they visit doctors, and that the disease is mild and does not necessitate a doctor’s visit are different self-treatment reasons that were reported in this study. In contrast, a quantitative study reported that patients’ self-medication practice is due to the absence of trust with the pharmacists, mainly because of their deficiency in requisite information provision.[35]

Our study reported that analgesics and antipyretics were the common OTC dispensed medications, followed by anti-cold drugs and anti-cough drugs. This is in agreement with other studies.[12,36,37,38] Even though less common, antibiotics were dispensed as OTC medications. Dispensing of antibiotics without a prescription would lead to misuse or overuse of antibiotics and this would not only result in recurrent infections and resistance to antibiotics but also increase the treatment cost and adverse effects.

According to our study, pharmacists were the main source of drug information for the patients, followed by internet and social networks. The findings of our study were similar to other studies which showed that patients mainly rely on pharmacist’s advice.[27,36] The pharmacists have a great desire to participate in continuous education and they had a strong belief that it would make a change in their professional service.[39] In the workplace, pharmacists should be given a chance to attend continuous education programs, which would improve their professional performance as well as the quality use of medications by the patients.

Community pharmacists’ opined that self-medication is unacceptable, but the patient became more aware of the importance of these errors, since most of the time it results in negative consequences. Self-medication may mask the correct diagnosis and may result in the false diagnosis.[40,41]

Strength

To the best of our knowledge, this is the first study carried out in Tabuk to study both the factors associated with dispensing errors and self-medication practices.

Limitation

The responses were subjective and hence there may be a chance of response bias that could have affected the results provided.

CONCLUSION

Self-medication practices and dispensing errors are widespread in Tabuk. Antibiotics were dispensed as OTC medication, which may lead to more chance of irrational drug use. Writing the prescription clearly and legibly would reduce dispensing errors. The Ministry of Health has enforced strict regulations and those regulations should be strictly followed by community pharmacists. It is the community pharmacists’ responsibility to increase awareness regarding the appropriate use of drugs by the public.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.