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      Prescribing errors and other problems reported by community pharmacists

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          Abstract

          Introduction:

          Prevention of medication errors is a priority for health services worldwide. Pharmacists routinely screen prescriptions for potential problems, including prescribing errors. This study describes prescribing problems reported by community pharmacists and discusses them from an error prevention perspective.

          Method

          For one month, nine community pharmacists documented prescribing problems, interventions made, and the proximal causes of the problems. The results were presented to local GPs and pharmacists at a meeting and feedback was invited.

          Results

          For 32 403 items dispensed, pharmacists reported 196 prescribing problems (0.6%). The reporting rates ranged from 0.2%–1.9% between pharmacists and were inversely correlated to dispensing volume. Prescriptions containing incomplete or incorrect information accounted for two-thirds of the problems. Lack of information on the prescriptions and transcribing/typing errors were the most frequently cited proximal causes. A few pitfalls of computerized prescribing were observed.

          Conclusion

          Although rates of prescribing problems reported were relatively low, community pharmacists and patients remain important safeguards. This study identified potential causes of prescribing errors, and illustrated areas which could be improved in the design of computerized prescribing systems, and the communication and sharing of information between GPs and pharmacists.

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          Most cited references 34

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          Human error: models and management.

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            Systems analysis of adverse drug events. ADE Prevention Study Group.

            To identify and evaluate the systems failures that underlie errors causing adverse drug events (ADEs) and potential ADEs. Systems analysis of events from a prospective cohort study. All admissions to 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Errors, proximal causes, and systems failures. Errors were detected by interviews of those involved. Errors were classified according to proximal cause and underlying systems failure by multidisciplinary teams of physicians, nurses, pharmacists, and systems analysts. During this period, 334 errors were detected as the causes of 264 preventable ADEs and potential ADEs. Sixteen major systems failures were identified as the underlying causes of the errors. The most common systems failure was in the dissemination of drug knowledge, particularly to physicians, accounting for 29% of the 334 errors. Inadequate availability of patient information, such as the results of laboratory tests, was associated with 18% of errors. Seven systems failures accounted for 78% of the errors; all could be improved by better information systems. Hospital personnel willingly participated in the detection and investigation of drug use errors and were able to identify underlying systems failures. The most common defects were in systems to disseminate knowledge about drugs and to make drug and patient information readily accessible at the time it is needed. Systems changes to improve dissemination and display of drug and patient data should make errors in the use of drugs less likely.
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              Causes of prescribing errors in hospital inpatients: a prospective study.

              To prevent errors made during the prescription of drugs, we need to know why they arise. Theories of human error used to understand the causes of mistakes made in high-risk industries are being used in health-care. They have not, however, been applied to prescribing errors, which are a great cause of patient harm. Our aim was to use this approach to investigate the causes of such errors. Pharmacists at a UK teaching hospital prospectively identified 88 potentially serious prescribing errors. We interviewed the prescribers who made 44 of these, and analysed our findings with human error theory. Our results suggest that most mistakes were made because of slips in attention, or because prescribers did not apply relevant rules. Doctors identified many risk factors-work environment, workload, whether or not they were prescribing for their own patient, communication within their team, physical and mental well-being, and lack of knowledge. Organisational factors were also identified, and included inadequate training, low perceived importance of prescribing, a hierarchical medical team, and an absence of self-awareness of errors. To reduce prescribing errors, hospitals should train junior doctors in the principles of drug dosing before they start prescribing, and enforce good practice in documentation. They should also create a culture in which prescription writing is seen as important, and formally review interventions made by pharmacists, locum arrangements, and the workload of junior doctors, and make doctors aware of situations in which they are likely to commit errors.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                December 2005
                December 2005
                : 1
                : 4
                : 333-342
                Affiliations
                [1 ]Department of Public Health and Epidemiology, University of Birmingham Birmingham, UK;
                [2 ]Pharmacist Nottingham, UK
                [3 ]Division of Primary Care, University of Nottingham Nottingham, UK
                [4 ]Institute of Psychiatry, King's College London London, UK
                [5 ]Nottingham Primary Care Research Partnership Nottingham, UK
                Author notes
                Correspondence: Yen-Fu Chen Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK Tel +44 121 414 6095 Fax +44 121 414 7878 Email y.chen.3@ 123456bham.ac.uk
                Article
                1661637
                18360575
                © 2005 Dove Medical Press Limited. All rights reserved
                Categories
                Original Research

                Medicine

                prescribing errors, general practice, community pharmacy

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