rss
Qual Saf Health Care 2007;16:285-290 doi:10.1136/qshc.2006.022053
  • Error management

Preventing medication errors in community pharmacy: root-cause analysis of transcription errors

  1. P Knudsen1,
  2. H Herborg1,
  3. A R Mortensen2,
  4. M Knudsen3,
  5. A Hellebek4
  1. 1Pharmakon, Danish College of Pharmacy Practice, Hillerød, Denmark
  2. 2The Danish Pharmaceutical Association, Copenhagen K, Denmark
  3. 3(Formerly) The Danish Pharmaceutical Association, Copenhagen K, Denmark
  4. 4Danish Society for Patient Safety, Hvidovre Hospital, Hvidovre, Denmark
  1. Correspondence to:
 P Knudsen
 Pharmakon a/s, Danish College of Pharmacy Practice, DK-3400 Hillerød, Denmark; pkn{at}pharmakon.dk
  • Accepted 30 January 2007

Abstract

Background: Medication errors can have serious consequences for patients, and medication safety is essential to pharmaceutical care. Insight is needed into the vulnerability of the working process at community pharmacies to identify what causes error incidents, so that the system can be improved to enhance patient safety.

Methods: 40 randomly selected Danish community pharmacies collected data on medication errors. Cases that reached patients were analysed, and the most serious cases were selected for root-cause analyses by an interdisciplinary analysis team.

Results: 401 cases had reached patients and a substantial number of them had possible clinical significance. Most of these errors were made in the transcription stage, and the most serious were errors in strength and dosage. The analysis team identified four root causes: handwritten prescriptions; “traps” such as similarities in packaging or names, or strength and dosage stated in misleading ways; lack of effective control of prescription label and medicine; and lack of concentration caused by interruptions.

Conclusion: A substantial number of the medication errors identified at pharmacies that reach patients have possible clinical significance. Root-cause analysis shows potential for identifying the underlying causes of the incidents and for providing a basis for action to improve patient safety.

Footnotes

    This Article

    1. Abstract
    2. Full text
    3. PDF

    Responses

    1. Submit a response
    2. No responses published

    Register for free content

    The full back archive is now available for all BMJ Journals. Institutional subscribers may access the entire archive as part of their subscription. Personal subscribers will also have access to all content when logged in. Non-subscribers who register have free access to all articles published before 2006 right back to volume 1 issue 1. Register here to access the free archive of all BMJ Journals.

    Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.