Table 1.
Study | Country | Type of study | Duration | Setting | Outcomes |
---|---|---|---|---|---|
Bohand et al23 | France | Prospective, direct observation by pharmacists and nurses to detect unit dose DEs | (2 months) March–April 2007 | Central pharmacy, unit dose for cardiovascular ward (30 beds) of the 354 bed Percy military hospital | 179 dispensing errors were detected from 7,249 units dose filled; the most common dispensing error types were incorrect dose 57 (31.8%) and omission 54 (30.2%). 86.6% of the DEs were detected by pharmacists during final check. |
James et al20 | UK | Retrospective, analyzed prevented and unprevented DEs reported to UK dispensing error analysis scheme (UKDEAS) | (3 months) September–December 2005 | 17 acute hospitals in Wales | 334 dispensing errors reported; 35 unprevented DEs and 339 prevented DEs. 157 (54%) of prevented DEs and 13 (37%) of unprevented DEs were labeling errors, for example, labeling wrong drug (prevented, n=15; unprevented n=6). Dispensed wrong drug strength (prevented, n=46; unprevented n=2). Look-alike/sound-alike, high workload, and inexperienced staff were the most commonly contributed factors reported. |
Irwin et al26 | UK | Retrospective, analyzed incident reports | (5 years) July 2005–March 2010 | 25 Scottish hospitals | 573 dispensing errors reported; the most frequent dispensing error types were dispensed wrong drug 110 (19.2%) and dispensed strength 96 (16.8%). The most frequent distributed factor reported were the medicines’ similarity in name, high workload, and inexperienced staff. |
Bonifacio Neto et al22 | Brazil | Prospective, direct observation | (2 months) July–August 2011 | Central pharmacy, unit dose for cardiovascular and pulmonary ward (36 beds) of the 280 bed university hospital | 1,611 dispensing errors were detected from 4,837 dispensed items; dispensed medicines without the described pharmaceutical form was the most common error (n=1,396, 86.6%). |
James et al21 | UK | Retrospective, analyzed incident reports | (2 years) January 2003–December 2004 | 20 Welsh NHS hospital pharmacies | 1,005 dispensing errors reported to UKDEAS; the most frequent errors were dispensed incorrect strength 241 (24%), incorrect drug 168 (17%), and wrong form 134 (13%). The most common medicine involved in DEs was insulin (n=34). Look-alike/sound-alike, high workload, low staffing, and inexperienced staff were the most commonly contributed factors reported. |
Beso et al25 | UK | Prospective by identified DEs in the final check, then interview with pharmacy staff who made the error to explore the causes | (2 weeks) June 17–28, 2002 | Teaching hospital in London (450 beds) | The rate of dispensing errors was 2.7% (130/4,849); dispensed wrong quantity was the most common errors (n=38, 29%), then labeling wrong quantity (n=18, 13.8%). High workload, low staff, interruptions, look-alike/sound-alike, and lack of knowledge about the availability of different medicines and formulation were the most common reported contribution factors. |
Anacleto et al29 | Brazil | Prospective, direct observation | (21 days) September 2002 | Unit dose in Belo Horizonte hospital pharmacy (286 beds) | 719 dispensing errors were detected from 2,143 dispensed items; the most frequent DEs were dose omission (n=412, 57.3%) and dispensing wrong quantity (n=91, 12.7%). |
Rolland34 | USA | Retrospective, analyzed incident reports | (4 years) October 1997–September 2001 | Eight different sections at Central Arkansas Veteran’s Healthcare System | 82 dispensing errors were reported; dispensing wrong medicines (n=31, 37.8%), dispensing to wrong patient (n=24, 29.2%), and dispensing wrong dose (n=21, 25.6%) were the most common DEs types. |
Seifert and Jacobitz32 | USA | Retrospective, chart review | (35 months) January 1999–November 2002 | All drug exposures reported to Midwest regional poison control centers | 40 dispensing errors reported among of 77,992 drug exposures reports; 20 DEs (50%) were substitution errors and 17 DEs (42.5%) were labeling errors. |
Rissato and Romano-Lieber30 | Brazil | Prospective, direct observation | (16 days) January 4–19, 2010 | Central pharmacy, unit dose for surgical ward (30 beds) of university hospital (104 beds) | 61 dispensing errors were observed from 1,963 prescribed drug items; the most frequent DEs were dose omission 14 (23%) and dispensed nonprescribed medication. |
Cina et al24 | USA | Prospective, direct observation | (7 months) February–August 2003 | Central pharmacy, unit dose at tertiary academic medical center (725 beds) | 5,075 (3.6%) dispensing errors were observed from 140,755 doses; 4,016 DEs prevented and 1,059 were unprevented DEs. The most frequent dispensing error types were dispensing wrong quantity (n=2,978, 59%), wrong strength (n=571, 11%), and wrong drug (n=554, 11%). |
Costa et al28 | Brazil | Prospective, direct observation | (27 days) 25 August–20 September | Central pharmacy, unit dose at pediatric hospital (96 beds) | 300 (11.5%) dispensing errors were observed from 2,620 observed doses. 43.3% missing dose, 25% dose added, and 13.3% omission. |
Anto et al31 | UK | Retrospective, analyzed incident reports | (4 years) January 2005–December 2008 | Two main pharmacies at NHS Foundation Hospital Trust in London (1,200 beds) | 911 prevented and unprevented dispensing errors; the most frequent DEs were dispensing wrong strength 13.4% (n=122), dispensing wrong drug 7.13% (n=65), and dispensing wrong form 2.6%. |
Bohand et al27 | France | Prospective, direct observation | (8 months) April–December 2006 | Central pharmacy, unit dose Percy military hospital (354 beds) | 706 dispensing errors were observed from 88,609 doses; the most dispensing error types were wrong dose (n=265, 37.5%) and omission dose (n=186, 26.3%). |
Anto et al33 | UK | Prospective, face-to-face interviews | (3 months) September–November 2008 | A 1,200 bed NHS Foundation Trust | 42 labeling incidents were recorded. The most common contributed factors were: high workload, limited staff, lack of knowledge, lack of concentration, hurrying through tasks, and illegible handwriting. |
Abbreviations: DE, dispending error; NHS, National Health Service.