A multicentre study of dispensing errors in British hospitals

Abstract

Nineteen hospital pharmacies in Britain participated in a study of dispensing errors. All dispensing errors (errors detected outside the department) and a sample of dispensing incidents (errors detected as part of the checking process) were recorded using a standard data collection form over a period of six months. One hundred and seventy-eight errors and 1,500 incidents were analysed. The overall error rate was 18.1/100,000 dispensed items (range 2.9–49.1/100,000). The mean error rate was 11.5/100,000 items in hospitals where all dispensing is checked and 35/100,000 items in hospitals where only items dispensed by non-pharmacists are checked. There were also differences in type between errors and incidents −31.7 per cent of incidents involved incorrect directions on the label compared with 17.4 per cent of errors; 34.2 per cent of incidents involved the wrong drug or drug strength being dispensed compared with 45.5 per cent of errors. One hundred and forty-five different drugs were involved in the 178 errors, with three drugs being involved in six errors each (flucloxacillin, glyceryl trinitrate and frusemide). The results of this study can contribute to the preparation of risk management strategies for dispensing.