Document Detail

Unprevented or prevented dispensing incidents: which outcome to use in dispensing error research?
MedLine Citation:
PMID:  21235658     Owner:  NLM     Status:  In-Data-Review    
Objectives  To compare the rate, error type, causes and clinical significance of unprevented and prevented dispensing incidents reported by Welsh National Health Service (NHS) hospital pharmacies. Methods  Details of all unprevented and prevented dispensing incidents occurring over 3 months (September-December 2005) at five district general hospitals across Wales were reported and analysed using a validated method. Rates of unprevented and prevented dispensing incidents were compared using Mann-Whitney U test. Reported error types, contributory factors and clinical significance of unprevented and prevented incidents were compared using Fisher's exact test. Key findings  Thirty-five unprevented and 291 prevented dispensing incidents were reported amongst 221 670 items. The rate of unprevented (16/100 000 items) and prevented dispensing incidents (131/100 000 items; P = 0.04) was significantly different. There was a significant difference in the proportions of prevented and unprevented dispensing incidents involving the wrong directions/warnings on the label (prevented, n = 100, 29%; unprevented, n = 4, 10%; P = 0.02) and the wrong drug details on the label (prevented, n = 15, 4%; unprevented, n = 6, 14%; P = 0.01). There was a significant difference in the proportions of prevented and unprevented dispensing incidents involving supply of the wrong strength (prevented, n = 46, 14%; unprevented, n = 2, 5%; P = 0.02) and issue of expired medicines (prevented, n = 3, 1%; unprevented, n = 5, 12%; P = 0.002). Conclusion  The use of prevented dispensing incidents as a surrogate marker for unprevented incidents is questionable. There were significant differences between unprevented and prevented dispensing incidents in terms of rate and error types. This is consistent with the medication error iceberg. Care must be exercised when extrapolating prevented dispensing incident data on error types to unprevented dispensing incidents.
K Lynette James; Dave Barlow; Robin Burfield; Sarah Hiom; Dave Roberts; Cate Whittlesea
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  The International journal of pharmacy practice     Volume:  19     ISSN:  0961-7671     ISO Abbreviation:  Int J Pharm Pract     Publication Date:  2011 Feb 
Date Detail:
Created Date:  2011-01-17     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  9204243     Medline TA:  Int J Pharm Pract     Country:  England    
Other Details:
Languages:  eng     Pagination:  36-50     Citation Subset:  IM    
Copyright Information:
© 2011 The Authors. IJPP © 2011 Royal Pharmaceutical Society.
Pharmaceutical Science Division, Clinical Practice & Medication Use Group, King's College London Pharmaceutical Science Division, Molecular Biophysics Groups, King's College London, London Health Solutions Wales St Mary's Pharmaceutical Unit University Hospital of Wales, Cardiff and Vale NHS Trust, Cardiff, Wales, UK.
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