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      The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study

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          Abstract

          Objectives

          To compare prevalence and types of dispensing errors and pharmacists’ labelling enhancements, for prescriptions transmitted electronically versus paper prescriptions.

          Design

          Naturalistic stepped wedge study.

          Setting

          15 English community pharmacies.

          Intervention

          Electronic transmission of prescriptions between prescriber and pharmacy.

          Main outcome measures

          Prevalence of labelling errors, content errors and labelling enhancements (beneficial additions to the instructions), as identified by researchers visiting each pharmacy.

          Results

          Overall, we identified labelling errors in 5.4% of 16 357 dispensed items, and content errors in 1.4%; enhancements were made for 13.6%. Pharmacists also edited the label for a further 21.9% of electronically transmitted items. Electronically transmitted prescriptions had a higher prevalence of labelling errors (7.4% of 3733 items) than other prescriptions (4.8% of 12 624); OR 1.46 (95% CI 1.21 to 1.76). There was no difference for content errors or enhancements. The increase in labelling errors was mainly accounted for by errors (mainly at one pharmacy) involving omission of the indication, where specified by the prescriber, from the label. A sensitivity analysis in which these cases (n=158) were not considered errors revealed no remaining difference between prescription types.

          Conclusions

          We identified a higher prevalence of labelling errors for items transmitted electronically, but this was predominantly accounted for by local practice in a single pharmacy, independent of prescription type. Community pharmacists made labelling enhancements to about one in seven dispensed items, whether electronically transmitted or not. Community pharmacists, prescribers, professional bodies and software providers should work together to agree how items should be dispensed and labelled to best reap the benefits of electronically transmitted prescriptions. Community pharmacists need to ensure their computer systems are promptly updated to help reduce errors.

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          Most cited references10

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          Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

          Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.
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            Electronic prescribing improves medication safety in community-based office practices.

            Although electronic prescribing (e-prescribing) holds promise for preventing prescription errors in the ambulatory setting, research on its effectiveness is inconclusive. To assess the impact of a stand-alone e-prescribing system on the rates and types of ambulatory prescribing errors. Prospective, non-randomized study using pre-post design of 15 providers who adopted e-prescribing with concurrent controls of 15 paper-based providers from September 2005 through June 2007. Use of a commercial, stand-alone e-prescribing system with clinical decision support including dosing recommendations and checks for drug-allergy interactions, drug-drug interactions, and duplicate therapies. Prescribing errors were identified by a standardized prescription and chart review. We analyzed 3684 paper-based prescriptions at baseline and 3848 paper-based and electronic prescriptions at one year of follow-up. For e-prescribing adopters, error rates decreased nearly sevenfold, from 42.5 per 100 prescriptions (95% confidence interval (CI), 36.7-49.3) at baseline to 6.6 per 100 prescriptions (95% CI, 5.1-8.3) one year after adoption (p < 0.001). For non-adopters, error rates remained high at 37.3 per 100 prescriptions (95% CI, 27.6-50.2) at baseline and 38.4 per 100 prescriptions (95% CI, 27.4-53.9) at one year (p = 0.54). At one year, the error rate for e-prescribing adopters was significantly lower than for non-adopters (p < 0.001). Illegibility errors were very high at baseline and were completely eliminated by e-prescribing (87.6 per 100 prescriptions at baseline for e-prescribing adopters, 0 at one year). Prescribing errors may occur much more frequently in community-based practices than previously reported. Our preliminary findings suggest that stand-alone e-prescribing with clinical decision support may significantly improve ambulatory medication safety. ClinicalTrials.gov, Taconic Health Information Network and Community (THINC), NCT00225563, http://clinicaltrials.gov/ct2/show/NCT00225563?term=Kaushal&rank=6 .
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              Prospective study of the incidence, nature and causes of dispensing errors in community pharmacies.

              Each year over 600 million prescription items are dispensed in community pharmacies in England and Wales. Despite this, there is little published evidence relating to dispensing errors and near misses occurring in this setting. This study sought to determine their incidence, nature and causes. Prospective study over a 4-week period in 35 community pharmacies (9 independent pharmacies and 26 chain pharmacies) in the UK. Pharmacists recorded details of all incidents that occurred during the dispensing process, including information about: the stage at which the error was detected; who found the error; who made the error; type of error; reported cause of error and circumstances associated with the error. 125,395 prescribed items were dispensed during the study period and 330 incidents were recorded relating to 310 prescriptions. 280 (84.8%) incidents were classified as a near miss (rate per 10,000 items dispensed=22.33, 95%CI 19.79-25.10), while the remaining 50 (15.2%) were classified as dispensing errors (rate per 10,000 items dispensed=3.99, 95%CI 2.96-5.26). Selection errors were the most common types of incidents (199, 60.3%), followed by labeling (109, 33.0%) and bagging errors (22, 6.6%). Most of the incidents were caused either by misreading the prescription (90, 24.5%), similar drug names (62, 16.8%), selecting the previous drug or dose from the patient's medication record on the pharmacy computer (42, 11.4%) or similar packaging (28, 7.6%). This study has demonstrated that a wide range of medication errors occur in community pharmacies. On average, for every 10,000 items dispensed, there are around 22 near misses and four dispensing errors. Given the current plans for reporting adverse events in the NHS, greater insight into the likely incidence and nature of dispensing errors will be helpful in designing effective risk management strategies in primary care. Copyright (c) 2004 John Wiley & Sons, Ltd.
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                Author and article information

                Journal
                BMJ Qual Saf
                BMJ Qual Saf
                qhc
                bmjqs
                BMJ Quality & Safety
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-5415
                2044-5423
                August 2014
                17 April 2014
                : 23
                : 8
                : 629-638
                Affiliations
                [1 ]Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital , London, UK
                [2 ]Department of Practice and Policy, UCL School of Pharmacy , London, UK
                [3 ]NHS Rushcliffe Clinical Commissioning Group, Easthorpe House , Nottingham, UK
                [4 ]Division of Primary Care, School of Medicine, University of Nottingham , Nottingham, UK
                [5 ]The NIHR Research Design Service for the East Midlands, School of Medicine, University of Nottingham, Queens Medical Centre , Nottingham, UK
                [6 ]Division of Social Research in Medicines and Health, University of Nottingham School of Pharmacy , Nottingham, UK
                [7 ]The Health Foundation , London, UK
                Author notes
                [Correspondence to ] Professor Bryony Dean Franklin, Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK; Bryony.deanfranklin@ 123456imperial.nhs.uk
                Author information
                http://orcid.org/0000-0002-8152-0870
                Article
                bmjqs-2013-002776
                10.1136/bmjqs-2013-002776
                4112418
                24742778
                8f8c6308-83dc-43d2-a099-fbc169dbc2c7
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/

                History
                : 19 December 2013
                : 25 March 2014
                : 1 April 2014
                Categories
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                1507
                Original Research
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                Public health
                Public health

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