Dispensing Errors – Dispensing Process
This audit is concerned with risk management of primary dispensing errors i.e.
those that occur during the dispensing process, rather than those that occur
outside of the pharmacy either as a result of the prescribing process, or as a
result of administration. The audit is designed to encourage greater
awareness amongst staff working in the dispensary of the stages in
dispensing when errors are most likely to occur, the types of errors that are
most likely to occur, and the circumstances when they are more likely to
occur.
It is important to realise that the audit will not identify who makes the most
errors. It has been found from piloting the audit that it is not possible to
compare the rates of errors either between staff or between pharmacies. This
is because the vigilance of the recording of the errors tends to vary between
staff and between pharmacies and this will skew any results. The audit will
enable pharmacists and their staff to learn from potential dispensing errors
and understand when they are more likely to make mistakes. This has been
shown to reduce the number of potential errors that occur.
The audit process allows staff to reflect on current practice and to design and
adopt policies and practices that minimise risk. Staff must be made aware
that the audit is not about disciplinary matters but about learning from our
practice and improving how we do things.
Experience from piloting of this audit has shown the following.
The interesting data to be found is in the possible causes of errors and the
factors affecting the error.
Causes of errors
The things that one might expect to see would be the issues over similar
packaging or similar names and issues over picking up the drug next to the
proper medicine. However, these were not the main problems. The most
frequent cause of mistake was misreading the prescription. This was usually
due to human error and poor handwriting was only highlighted in a very few
cases.
The major causes of problems were typing/computer errors and misreading
prescriptions. The typing/computer errors include typing mistakes, incorrect
selection form the computer and using the previous drug/dose on PMR.
These are errors that are directly related to how people use the PMR and how
carefully they check the details before they press return.
The misreading of prescriptions may be a problem of thoroughness and
speed and may be due to the speeding and the volume of prescriptions.
The errors to do with similar drug names or similar packaging were significant
but not as frequent as might be expected. These, however, are the ones that
you can do something about.
Picking errors, i.e. picking the next medicine on the shelf or a medicine being
in the wrong place, were not that frequent. This is something that one can
take precautions over such as separating similarly packed drugs from each
other.
It was interesting that poor prescribing in terms of handwriting or ambiguous
directions are relatively rare problems.
Factors affecting the error
The most common factors affecting the error are to do with being busier than
normal or interruptions. If you combine the factors that could describe how
busy the pharmacy is (busier than normal and less staff than normal), it was
clear that being busier then normal is the biggest factor. There is little that
one can do about being busy except be aware that you might make mistakes.
Interruptions are the next biggest factor (telephone interruption, busy counter
business, query from member of staff, etc.). This is predictable, but it is
surprising how many pharmacists will attempt to keep dispensing when they
are on the phone, etc. The lesson from this is to either delegate answering
the phone, etc. or to stop dispensing while dealing with an interruption.
There are other categories that are worth highlighting as well. About 10% of
errors occurred when the pharmacy was less busy than normal. This is a
finding that surprised us when we did the piloting of this audit. It may be that
when things are quiet the pharmacist is more relaxed and not concentrating
as much.
The factors relating to new or unusual staff are also significant, because this
will apply to new staff and locums, etc. It does not imply that locums or new
staff are poor quality just that they are not used to the pharmacy and therefore
have added pressures.
The final point is the time of day problem. In piloting, about 5% of errors listed
this as a possible cause. This might be first thing in the morning for some
people or last thing at night for others. Individuals need to realise that they
will perform differently at different times of day and make allowances for this.
Aims and Objectives
•
•
•
•
•
•
•
To describe errors that occur during the dispensing process to support
risk management
To identify and address stage/s in the dispensing process when errors
most commonly occur
To review the frequency of errors made during the dispensing process
To identify and address common types of dispensing errors that occur
To identify and address common causes of dispensing errors that
occur
To identify and address factors or circumstances that are associated
with the occurrence of dispensing errors
To identify appropriate preventative action in response to dispensing
errors
Criteria
•
•
•
•
•
•
Full details of errors occurring during the dispensing process should be
recorded
Pharmacists and their staff should be aware of the stage/s of
dispensing when errors most commonly occur
Pharmacists and their staff should be aware of the type/s of errors that
most commonly occur
Pharmacists and their staff should be aware of the causes of errors
that most commonly occur
Pharmacists and their staff should be aware of circumstances when
dispensing errors most commonly occur
Pharmacists and their staff should be made aware of the frequency
with which they make errors
Data Collection
Data used:
• Status of pharmacist on duty
• Stage at which error detected
• Person identifying error
• Person/s making error
• Type and nature of error
• Possible cause of error
• Circumstances associated with error
• Date error occurred
• Time error detected
• Branch ID (for chains/multiples only)
Completing the Audit Form
Please report all errors, including those that you detect during the normal
process of dispensing. Unsigned or illegal prescriptions should be included if
they were dispensed or the dispensing process was started before the lack of
a signature, etc was spotted. It is believed that we can learn from the errors
that are detected during dispensing as well as those that get as far as the
patient.
These guidance notes give details about how to use the Dispensing Process
Audit Form.
Branch ID – If you are part of a multiple or group of pharmacies sharing
results, you will need to complete this.
Date and Time – please enter the date and time that the error took place.
Contact name – please give the name of a contact in the store that was
present when the error occurred. This is in case a follow up of the error is
needed to get more details.
Pharmacist on duty – please note the type of pharmacist on duty when the
error occurred. Some of these categories may not apply to your pharmacy,
but will apply in other pharmacies.
Stage at which error detected – Did the patient or patient’s representative
report the error, or did you detect it during your dispensing, checking or
handing out procedure.
Who found the error/Who made the error – these questions ask about how
the error was discovered and the grade of staff who made the error. It is not
important to know the names of the staff involved only their positions.
Type of error – what type of error was made. This has been split into
labelling errors, selection errors and bagging errors. A dispensing error may
involve more than one type of error e.g. misreading a prescription written as
Capoten 12.5mg and dispensing Capoten 25mg may involve an error in
labelling and an error in selection.
1. Labelling Errors
Wrong drug/form on label
Wrong strength on label
Wrong directions on label
Wrong patient name on label
Wrong quantity on label
Wrong label on container
2. Selection Errors
Wrong drug/form selected
Wrong strength selected
Wrong quantity counted
3. Bagging Errors
Wrong name on bag
Wrong address on bag
Item omitted from bag
Extra item in bag
wrong drug name or form on label
(e.g. ointment instead of cream)
e.g. 25mg instead of 50mg on label
e.g. one three times a day instead of
One twice a day
Do not include examples of spelling
mistakes
e.g. 28 tablets instead of 56 tablets
on label
Labels swapped with those belonging
to another drug or patient
Incorrect drug or form dispensed
e.g. 25mg instead of 50mg dispensed
e.g. 28 tablets instead of 56 tablets
dispensed
Do not include examples of spelling
mistakes
Do not include examples of spelling
mistakes
e.g. two items in bag instead of three
items
e.g. an extra item from another
patient is included in the bag
Brief description of the error
Please give brief details about what the error was e.g. Amoxycillin
125mg/5mg prescribed, Amoxycillin 250mg/5mg dispensed
Possible causes of error
This is the most important piece of information that we need. What caused
the mistake to happen?
Here is a list of several possible causes of the error. This list is not
exhaustive, so can be added to. The reason for the error may not be
immediately obvious so think carefully about the real reason and if the reason
is not known please state that.
Drug Selection
Similar drug name
Similar packaging
Picked next medicine on shelf
Medicine in wrong place on shelf
e.g. Zestril or Zocor
e.g. generics that are similarly
labelled and packaged
Did you pick up the medicine that was
next to the one you wanted on the
shelf?
Has a drug been put back in the
wrong place e.g. ear drops on the eye
drops shelf
Prescription
Poor handwriting on the Rx
Ambiguous directions on the Rx
Misread prescription
Typing mistake
Computer/Counter
Incorrect drug selected
Used previous drug/dose on PMR
Labels swapped from same Rx
Labels swapped from different Rxs
Tablet counting error
Other
Was the prescription difficult to read?
Were the directions on the
prescription unclear?
e.g. misread prescription quantity as
28 instead of 56
e.g. typing incorrect code into
computer
Selected wrong drug/form/strength
from the list displayed on the
computer. This is different to a typing
error.
Did you repeat the details from the
patient’s last prescription on the PMR
without noting any changes on the
current prescription?
Were the labels put on the wrong
bottles but for the right patient?
Were the labels put on a different
person’s prescription?
e.g. tablet counter was dusty and
miscounted number of tablets
Can you think of any other cause for
the error? Please give us some
details so that they can include it in
the analysis
Other factors affecting the error
We all know that errors are more likely to occur when we are busier than
normal or interrupted during dispensing. These are not the prime causes of
the error, but could have contributed to it. We would like to identify any
factors that are felt may have contributed to the error occurring.
Here is a list.
Busyness
Busier/quieter than normal
Time of day
Staffing
Less staff than usual
Not usual pharmacist/dispenser
Was the pharmacy busier or quieter
than normal?
Did the mistake happen as you were
about to close or just after you
opened, etc?
Were there fewer staff than normally
man the pharmacy?
Were some of the usual dispensary
staff absent?
Distractions
Telephone interruption
Staff query
Customer/patient query
Busy OTC trade
Other
Did you have to answer the phone
while you were dispensing?
Were you interrupted during
dispensing by a query from a member
of staff?
Were you interrupted during
dispensing by a query from a
customer/patient?
Were customers waiting to see you or
asking you questions?
Can you think of any other factors
affecting the error? Please give us
some details so that they can include
it in the analysis
Instructions
Suggested duration of audit:
1 month
(Follow up on outcomes may continue for longer)
Scripts to be included:
All NHS and private scripts
Standards Set
Based on evidence of risk and your own professional judgement
• _______ % of error forms contain full details
•
_______ staff are aware of the stage/s at which dispensing errors most
commonly occur
•
_______ staff are aware of the type/s of dispensing errors that most
commonly occur
•
_______ staff are aware of the cause/s of dispensing errors that most
commonly occur
•
_______ staff are aware of the circumstance/s when dispensing errors
most commonly occur
•
_______ staff are aware of the frequency with which they are involved
in errors
Action Points
Although this audit is based o the available evidence, your actions, will, to
some extent, need to reflect your working environment. Based on the
information gathered in preparation for this audit list any amendments to the
suggested action points and / outcomes shown on the data collection form as
well as recording them in the box below.
Collect data
To help you familiarise yourself with the data collection form the
accompanying chart provides descriptions of the information that is required.
The form can be adapted to reflect action points identified and/or outcomes
that are more suited to the practice.
Use one form per incident. Keep the forms close to the dispensary so that all
the staff can find them easily when an error is detected.
Transfer data
Transfer information from the data collection forms to the results table.
Data Analysis
The analysis for this audit consists of simple ranking.
Potential Benefits
Pharmacists
Feedback on common dispensing errors
Support to address common causes
Demonstration of good practice
Ability to support dispensing staff
Pharmacy Dispensing Staff
Feedback on common
dispensing errors
Improved training
Patients
Reliable high quality service
Superintendent
Demonstration of good practice
Risk management
Ability to address avoidable causes of dispensing errors
Overview of dispensing process
Ability to monitor trends in dispensing errors
Results
Total number of items dispensed during audit period : _________________
Pharmacist on duty
No. of 1o dispensing errors
Ranked
(most common = 1)
Area manager
Branch Manager/Proprietor
District manager
Second pharmacist
Relief pharmacist
Locum pharmacist
Errors most commonly occur when the duty pharmacist is ___________
Stage at which error
detected
Labelling
Dispensing
Final check
Bagging up
Handing out
Patient/representative
Other (give details below)
No. of 1o dispensing errors
Ranked
(most common = 1)
Errors are most commonly detected at the _______________ stage of the
dispensing process
Person finding error
No. of 1o dispensing errors
Ranked
(most common = 1)
Pharmacist
Dispenser
Counter assistant
Pre-reg pharmacist
Patient/representative
The person most likely to find errors is ___________________________
Person/s making error
No. of 1o dispensing errors
Ranked
(most common = 1)
Pharmacist
Dispenser
Counter assistant
Pre-reg pharmacist
The grade of staff most likely to make errors _______________________
Type of error
No. of 1o dispensing errors
Ranked
(most common = 1)
Labelling
Selection
Bagging
The most common type of error is ___________________
Of these the following particular problems occur most frequently
Possible cause of error
No. of 1o dispensing errors
Ranked
(most common = 1)
Drug selection
Prescription
Computer/counter
The most common possible cause of error is ______________________
Of these the following particular causes occur most frequently
Circumstances
associated with error
Business
Staffing
Distractions
No. of 1o dispensing errors
Ranked
(most common = 1)
The most common circumstances associated with error is ____________
Of these the following particular circumstances occur most frequently
Summary of findings
The audit was carried out between __________ and ______________
___________ staff were involved in the audit
During this time _______ prescriptions were dispensed
Errors most commonly occur when the duty pharmacist is ___________
(status)
Errors are most commonly detected at _____________ stage of the
dispensing errors
The person most likely to find errors is ____________ (job title)
The grade of staff most likely to make errors is __________ (job title)
The most common type of error is ______________________
→Of these the following particular problems occur most frequently
The most common possible cause of error is ____________________
→Of these the following particular causes occur most frequently
The most common circumstance associated with error is ______________
→Of these the following particular circumstances occur most frequently