Retrospective analysis of DATIX dispensing error reports from Scottish NHS hospitals

Abstract

The primary objective was to analyse reported dispensing errors, and contributing factors, in Scottish National Health Service hospitals by coding and quantifying error reports from the DATIX patient-safety software. The secondary objective was to gather managerial responses to dispensing error in order to gain a perspective on interventions already in place. Incident reports collected from 23 Scottish hospitals over a 5-year period were analysed retrospectively. Reported incident types, contributory factors and managerial responses were categorised according to the event description, and the frequency of such factors calculated. Dispensing errors (n = 573), from both pharmacies and wards, were analysed. The main incident types were incorrect drug (19.2%, n = 110) and incorrect strength of drug (16.8%, n = 96). The main contributory factors were reported as drug name similarity (15.5%, n = 30) and busy wards/pharmacies (14.9%, n = 29). Patient-centred issues (6.1%, n = 12) also featured. Managerial responses to these errors took the form of meetings (16.7%, n = 42), increasing staff awareness (14.7%, n = 37) or staff reminders on the importance of checking procedures (17.9%, n = 45). The pattern of incidents reported is similar to previous research on the subject, but with a few key differences, such as, reports of errors associated with filling dosette boxes, and patient-centred issues. These differences indicate a potentially changing pattern of errors in response to new techniques in medicine management. Continued assessment of dispensing errors is required in order to develop practical interventions to improve medication safety.