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CP-015 An evaluation of the types and contributing factors of dispensing errors in hospital pharmacy
  1. K Aldhwaihi1,
  2. N Umaru2,
  3. C Pezzolesi3,
  4. F Schifano2
  1. 1University of Hertfordshire, Department of Pharmacy- Pharmacology and Postgraduate Medicine, Hatfield, UK
  2. 2University of Hertfordshire, Department of Pharmacy- Pharmacology and Postgraduate Medicine, Hatfield, UK
  3. 3University of Hertfordshire, Department of Pharmacy- Pharmacology and Postgraduate Medicine, Hatfield, UK


Background Dispensing medication is a chain of multiple stages, and any error during the dispensing process may cause high potential risk for the patient. Few research studies have investigated the nature and the contributory factors that are associated with dispensing errors in hospital pharmacies.

Purpose To determine the nature and severity of unprevented dispensing errors reported in the hospital pharmacy at Luton and Dunstable Hospital in the UK; and to explore the pharmacy staff’s perceptions of contributory factors to dispensing errors and strategies to reduce these errors.

Material and methods A mixed method approach was used and encompassed two phases. Phase I: a retrospective review of dispensing error reports for an 18 month period from 1 January 2012 to 30 June 2013 was conducted. An assessment of the potential clinical significance of the dispensing errors was undertaken. Data were analysed using descriptive statistics. Phase II: self-administered qualitative questionnaires were distributed to the dispensary team at the hospital. Content analysis using NVivo software was undertaken.

Results 766 medication error reports were documented and 49 (6.4%) reports were related to dispensary incidents. The most frequently reported dispensing errors were: dispensing the wrong medicine (n = 9, 18.4%), labelling the wrong strength (n = 8, 16.3%) and dispensing the wrong strength (n = 7, 14.3%). The majority of the dispensing errors had minor or moderate potential to harm patients. Look-alike/sound-alike medicines, high workload, lack of staff experience, fatigue and loss of concentration during work, hurrying through tasks and distraction in the dispensary were the most common contributory factors. Furthermore, ambiguity of the prescriptions was also reported as a contributory factor in the hospital.

Conclusion Decreasing distractions in the pharmacy are needed to enhance patient safety. Furthermore, monitoring and reporting errors, and educating the dispensary team about these errors are also needed. An e-prescribing system may help to improve dispensing efficiency and safety. The findings of this study re-emphasise the fact that dispensing errors are widespread in hospital pharmacy. Therefore, efficient interventions need to be implemented to mitigate these errors.

References and/or Acknowledgements Many thanks to the Saudi Ministry of Health for the scholarship and funding my study

No conflict of interest.

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