1. Analysis of the Reporting and Classification
of Dispensing Errors
Malcolm Clubb, Deputy Superintendent, Lindsay and Gilmour. 19 Smith’s Place , Edinburgh, EH6 8NU
Louise Evans, Teaching Associate, University of Strathclyde. 161 Cathedral Street, Glasgow, G4 0RE
Situation
Assessment
Lindsay & Gilmour is a group of 29 community pharmacies spread across East and Central Scotland, the Borders and Fife. We offer a full range of modern pharmacy services.
We are keen to support a ‘no-blame’ culture, where learning from every dispensing error that is reported to Head Office is circulated, to allow all team members to review their own practice and ensure risks are minimised for patients using the organisation.
We are concerned that our current process for error review does not support the reporting back to branches on an annualised basis.
A sample of error report forms collected between May–October 2017 were analysed.
Branches included in the study were coded ‘A’ to ‘F’ in order to ensure anonymity. Table 1 shows the rate of near misses, dispensing errors and combined total for each branch.
Further investigation revealed that the most common error/near miss type was selection errors (wrong drug/form/strength/quantity).
Calculated error rates in this investigation were found to be lower than the average rates described by studies using the same classification system and denominator for rate calculation.
This could be due to under-reporting of errors or near misses by staff due to time pressures, or difficulties created by the reporting system itself. Alternatively, the branches studied here may be exemplars of safe dispensing, which could provide learning opportunities for other branches. Further work is needed to explore this.
Background
In their strategy document: ‘Achieving Excellence in Pharmaceutical Care’, the Scottish Government described the need for ‘assessment, assurance and improvement’ in order to reduce preventable harm from medicines As part of the Scottish Patient Safety Programme, Pharmacy Safety Climate Surveys were completed by all Lindsay and Gilmour branches on at least one occasion prior to this study.
Building upon this, as part of a continuous improvement programme, internally recorded dispensing error data was analysed in November 2017 in order to identify trends and areas of priority for future work.
Using definitions previously established by Ashcroft et al2, details of ‘near misses’ and ‘dispensing errors’ which had been reported to Head Office were entered into a database and analysed according to type and frequency (total dispensed items per branch was used to calculate error rates).
Error types include: selection, labelling and bagging errors2. Error rates identified in previous UK studies using the same definitions and calculation ranged from 0.22% to 0.48% (‘near misses’) and 0.04% to 0.08% (‘dispensing errors’)3.
Table 1. Dispensing error, near miss and combined rates
Recommendations
Following this initial study, the next stages of evaluation and improvement will include: a study focussing on the root cause analyses of selection errors/near misses, and: an anonymised survey of staff attitudes towards the current reporting system.
Acknowledgements
We would like to thank Sarah Cairney and Emily Sadiq, for completing this initial data analysis as part of their MPharm final year projects.
NHS Scotland. Achieving excellence in pharmaceutical care: a strategy for Scotland. Available at: (accessed August 2018)
2. Ashcroft D, Quinlan P, Blenkinsopp A. Prospective study of the incidence, nature and causes of dispensing errors in community pharmacies.
Pharmacoepidemiology and Drug Safety. 2005;14(5):
3. James K et al. Incidence, type and causes of dispensing errors: a review of the literature. International Journal of Pharmacy Practice. 2009;17(1):9-
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