ArticlePharmacy world & science : PWS2005
The frequency and potential causes of dispensing errors in a hospital pharmacy.
Article in Pharmacy world & science : PWS, 2005. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 53 papers, 1 of them a synthesis that pooled it.
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Who cites it
53 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review.BMJ quality & safety · 2012Pooled it
- Right-brain utilization in pharmacists' dispensing processes: an eye-tracking analysis of efficiency and safety using error-induction models.Journal of pharmaceutical health care and sciences · 2025Article
- Analysis of Drug Product Dispensing Error Characteristics, Construction and Evaluation of a Risk Warning Model in Outpatient Pharmacy: A Retrospective Study in China.Risk management and healthcare policy · 2025Article
- Eye-tracking-based analysis of pharmacists' thought processes in the dispensing work: research related to the efficiency in dispensing based on right-brain thinking.Journal of pharmaceutical health care and sciences · 2024Article
- Impact of implementing the aseptic compounding management system, Medcura, on internal error rates within an oncology pharmacy aseptic unit: a mixed methods evaluation.European journal of hospital pharmacy : science and practice · 2024Article
- A refined management system focusing on medication dispensing errors: A 14-year retrospective study of a hospital outpatient pharmacy.Saudi pharmaceutical journal : SPJ : the official publication of the Saudi Pharmaceutical Society · 2023Article
- An observational study of the cause and frequency of prescription rework in community pharmacies.International journal of clinical pharmacy · 2023Observational
- Analysis of the thinking process of pharmacists in response to changes in the dispensing environment using the eye-tracking method.Journal of pharmaceutical health care and sciences · 2022Article
- Medication-related adverse events in health care-what have we learned? A narrative overview of the current knowledge.European journal of clinical pharmacology · 2022Review
- Liability for Dispensing Errors in Hong Kong.Asian bioethics review · 2021Article
- The Myth of Multitasking and What It Means for Future Pharmacists.American journal of pharmaceutical education · 2021Article
- Nature of dispensing errors in selected hospitals providing free healthcare: a multi-center study in Sri Lanka.BMC health services research · 2020Article
- Categorizing and understanding medication errors in hospital pharmacy in relation to human factors.Saudi pharmaceutical journal : SPJ : the official publication of the Saudi Pharmaceutical Society · 2020Article
- Dispensing errors and self-medication practice observed by community pharmacists in Jordan.Saudi pharmaceutical journal : SPJ : the official publication of the Saudi Pharmaceutical Society · 2020Article
- Identifying dispensing errors in pharmacies in a medical science school in Trinidad and Tobago.Journal of pharmaceutical policy and practice · 2020Article
- New Users of Herbal Medicine Containing Aristolochic Acids and the Risk of Dementia in the Elderly: A Nationwide, Population-Based Study in Taiwan.Neuropsychiatric disease and treatment · 2020Article
- A mixed methods analysis of lithium-related patient safety incidents in primary care.Therapeutic advances in drug safety · 2020Article
- Observational
- Integration of a Commercial Barcode-Assisted Medication Dispensing System in a Teaching Hospital.Applied clinical informatics · 2019Article
- Contributing factors to outpatient pharmacy near miss errors: a Malaysian prospective multi-center study.International journal of clinical pharmacy · 2019Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
3 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectivesTo determine the frequency and types of dispensing errors identified both at the final check stage and outside of a UK hospital pharmacy, to explore the reasons why they occurred, and to make recommendations for their prevention.
methodA definition of a dispensing error and a classification system were developed. To study the frequency and types of errors, pharmacy staff recorded details of all errors identified at the final check stage during a two-week period; all errors identified outside of the department and reported during a one-year period were also recorded. During a separate six-week period, pharmacy staff making dispensing errors identified at the final check stage were interviewed to explore the causes; the findings were analysed using a model of human error.
main outcome measuresPercentage of dispensed items for which one or more dispensing errors were identified at the final check stage; percentage for which an error was reported outside of the pharmacy department; the active failures, error producing conditions and latent conditions that result in dispensing errors occurring.
resultsOne or more dispensing errors were identified at the final check stage in 2.1% of 4849 dispensed items, and outside of the pharmacy department in 0.02% of 194,584 items. The majority of those identified at the final check stage involved slips in picking products, or mistakes in making assumptions about the products concerned. Factors contributing to the errors included labelling and storage of containers in the dispensary, interruptions and distractions, a culture where errors are seen as being inevitable, and reliance on others to identify and rectify errors.
conclusionDispensing errors occur in about 2% of all dispensed items. About 1 in 100 of these is missed by the final check. The impact on dispensing errors of developments such as automated dispensing systems should be evaluated.
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16096885What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.