Retrospective analysis of DATIX dispensing error reports from Scottish hospitals

Aim 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.
Methods Incident reports collected from23 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.
Key findings 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).
Conclusions 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.