Retrospective analysis of DATIX dispensing error reports from Scottish hospitals

Amy Louise Irwin, Jennifer Ross, Janet Seaton, Kathryn Jane Mearns

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

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.
Original languageEnglish
Pages (from-to)417 - 423
Number of pages7
JournalInternational Journal of Pharmacy Practice
Volume19
Issue number6
Early online date23 Jun 2011
DOIs
Publication statusPublished - Dec 2011

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Pharmacies
Pharmaceutical Preparations
National Health Programs
Patient Safety
Names
Software
Medicine
Safety
Research
Health

Keywords

  • DATIX
  • dispensing error
  • pharmacist
  • ward

Cite this

Retrospective analysis of DATIX dispensing error reports from Scottish hospitals. / Irwin, Amy Louise; Ross, Jennifer; Seaton, Janet; Mearns, Kathryn Jane.

In: International Journal of Pharmacy Practice, Vol. 19, No. 6, 12.2011, p. 417 - 423.

Research output: Contribution to journalArticle

Irwin, Amy Louise ; Ross, Jennifer ; Seaton, Janet ; Mearns, Kathryn Jane. / Retrospective analysis of DATIX dispensing error reports from Scottish hospitals. In: International Journal of Pharmacy Practice. 2011 ; Vol. 19, No. 6. pp. 417 - 423.
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abstract = "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.",
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