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National Observational Study Of Prescription Dispensing Accuracy And Safety In 50 Pharmacies.

E. Flynn, K. Barker, B. Carnahan
Published 2003 · Medicine

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OBJECTIVES To measure dispensing accuracy rates in 50 pharmacies located in 6 cities across the United States and describe the nature and frequency of the errors detected. DESIGN Cross-sectional descriptive study. SETTINGS Chain, independent, and health-system pharmacies (located in hospitals or managed care organizations). PARTICIPANTS Pharmacy staff at randomly selected pharmacies in each city who accepted an invitation to participate. INTERVENTION Observation by a pharmacist in each pharmacy for 1 day, with a goal of inspecting 100 prescriptions for dispensing errors (defined as any deviation from the prescriber's order). MAIN OUTCOME MEASURE Dispensing errors on new and refill prescriptions. RESULTS Data were collected between July 2000 and April 2001. The overall dispensing accuracy rate was 98.3% (77 errors among 4,481 prescriptions; range, 87.2%-100.0%; 95.0% confidence interval, ± 0.4%). Accuracy rates did not differ significantly by pharmacy type or city. Of the 77 identified errors, 5 (6.5%) were judged to be clinically important. CONCLUSION Dispensing errors are a problem on a national level, at a rate of about 4 errors per day in a pharmacy filling 250 prescriptions daily. An estimated 51.5 million errors occur during the filling of 3 billion prescriptions each year.
This paper references
Wrong drug: A medication that is different from what the prescriber wrote on the prescription order or, for refill prescriptions
Surveyor Procedures for Pharmaceutical Service Requirements in Long-Term Care...
U. Services (1990)
Pharmacists' Assessment of Dispensing Errors: Risk Factors, Practice Sites, Professional Functions, and Satisfaction
C. Bond (2001)
Wrong strength: A dosage unit containing an amount of medication that is different from what the prescriber specified is dispensed without an adjustment to the dosing instructions to the patient
Relationships between Ambient Sounds and the Accuracy of Pharmacists' Prescription-Filling Performance
E. Flynn (1996)
Evaluation of two concurrent drug-delivery systems in a skilled-nursing facility.
D. Reitberg (1982)
Effect of an automated bedside dispensing machine on medication errors.
K. Barker (1984)
Comparison of medication-error detection methods in the long term care facility
RC Shannon (1987)
Effect of an automated, nursing unit-based drug-dispensing device on medication errors.
J. Borel (1995)
Omission: Failing to dispense a prescribed medication
The development of a centralized unit-dose dispensing system for UAMC. Pt. 6: the pilot study--medication errors and drug losses.
Kenneth N. Barker (1964)
Medication errors reduced by unit-dose.
Shultz Sm (1973)
Medication errors in a multidose and a computer-based unit dose drug distribution system.
B. Means (1975)
Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities.
E. Flynn (2002)
Medication Errors: Causes, Prevention, and Risk Management
M. Cohen (1999)
A Study of Patient Care Involving a Unit Dose System.
Madden Ee (1968)
Quality of Pharmaceutical Care in Small Hospitals
WM Brown (1976)
A Randomized Trial Comparing Pharmacists and Technicians as Dispensers of Prescriptions for Ambulatory Patients
W. Mcghan (1983)
Medication error research
EA Flynn (1999)
A study of unit-dose drug distribution in four Canadian hospitals.
B. Schnell (1976)
Illumination and errors in dispensing.
T. L. Buchanan (1991)
Facts and Comparisons
Sister Mary Berenice (1951)
Appendix N — Surveyor procedures for pharmaceutical service requirements in long - term care facilities
KN Barker (2002)
Accuracy of dispensing in a high-volume, hospital-based outpatient pharmacy.
U. A. Kistner (1994)
Rules outside the rules for administration of medication: a study in New South Wales, Australia.
H. Baker (1997)
Effect of automation on errors
J Carper
Manufacturer Rx sales top $120 billion
C Ukens
Research on drug-use-system errors.
K. Barker (1995)
The effects of an experimental medication system on medication errors and costs. I. Introduction and errors study.
K. Barker (1969)
A study of unit-dose drug distribution in four Canadian hospitals.
Schnell Br (1976)
Observational study of factors associated with prescription dispensing errors in 50 pharmacies. Abstract presented at
E Flynn
Pharmacists’ impact on medication administration errors in long-term care facilities
DM Ruffin (1995)
Medication errors in a pharmacy-coordinated drug administration program.
K. Jozefczyk (1986)
Metropolitan Area Rankings by Population Size and Percent Change for
U S Bureau
Observational study of factors associated with prescription dispensing errors in 50 pharmacies
E Flynn (2003)
Pharmacists' Dispensing Accuracy in a High-Volume Outpatient Pharmacy Service: Focus on Risk Management
B. Guernsey (1983)
Computational Handbook of Statistics
J. Bruning (1968)
Medication errors in nursing homes and small hospitals.
K. Barker (1982)
The Problems of Detecting Medication Errors in Hospitals
K. Barker (1962)
The ABCs of drugstores
Comparison of medication errors in an American and a British hospital.
B. Dean (1995)
A comparison of medication errors under the University of Kentucky unit dose system and traditional drug distribution systems in four hospitals.
C. E. Hynniman (1970)
Quality of Pharmaceutical Care in Small Hospitals. Kansas City, Mo: Missouri Regional Medical Program
W M Brown (1976)
Hatfield GM , Hanson EC . Dispensing errors and detection at an outpatient pharmacy
TJ Spader
Consultant evaluation of a hospital medication system: analysis of the existing system.
K. Barker (1984)
Automated medication packaging for long-term care facilities: evaluation
S Cooper (1994)
A Study of Medication Errors in a Hospital
KN Barker (1966)
Relationships Among Facility Design Variables and Medication Errors in a Pharmacy [dissertation
EL Allan (1994)
A study pre and post unit dose conversion in a pediatric hospital.
M. O'Brodovich (1991)
Into the abyss: seven principles for identifying the causes of and preventing human error in complex systems.
A. F. Grasha (2000)
Patient counseling detects prescription errors.
A. Kuyper (1993)
Validity and reliability of observational methods for studying medication administration errors.
B. Dean (2001)
Data collection techniques: observation.
K. Barker (1980)
Medication errors reduced by unit-dose.
S. M. Shultz (1973)
[To err is human: building a safer health system].
P. Maurette (2002)
Patient counseling detects prescription errors.
Kuyper Ar (1993)
Metropolitan Area Rankings by Population Size and Percent Change for July 1, 1998 to July 1, 1999 and April 1, 1990 to July 1, 1999
U. S. Census Bureau (2003)
Dispensing errors and detection at an outpatient pharmacy
GM SpaderTJ.Hatfield (1995)
Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy.
E. Flynn (1999)
Manufacturer Rx sales top $120 billion, IMS reports
C. Ukens (2000)
Medication errors reduced by unitdose. Hospitals
SM Shultz (1973)
Relationships Among Facility Design Variables and Medication Errors in a Pharmacy
E L Allan
The development of a centralized unit dose dispensing system. Part six: the pilot study—medication errors and drug losses
KN Barker (1964)
Comparison of a Traditional and Unit Dose Drug Distribution System in a Nursing Home
H. K. Crawley (1971)

This paper is referenced by
An ocular medication dispensing error.
E. Mein (2006)
Comparison of two error-detection methods in a mail service pharmacy serving health facilities.
R. Varadarajan (2008)
Prescription for Error: Process Defects in a Community Retail Pharmacy
D. Witte (2007)
A systematic approach of tracking and reporting medication errors at a tertiary care university hospital, Karachi, Pakistan
Khurshid Khowaja (2008)
When to Ignore What Users Say
Devorah E. Klein (2006)
Types, Prevalence, and Potential Clinical Significance of Medication Administration Errors in Assisted Living
H. Young (2008)
Medical error reporting among physicians and nurses in Uganda
Gideon Mauti (2019)
Drug name confusion: evaluating the effectiveness of capital ("Tall Man") letters using eye movement data.
Ruth Filik (2004)
Identification of potential drug name confusion errors in the Sentinel System
N. Cocoros (2019)
Impact of Live Training on Medication Errors in a Community-Based Pharmacy Setting
Morgan Grant (2020)
Evaluation of Drug Label Designs Using Eye Tracking
A. Bojko (2005)
Improving Quality and Safety through Human Factors Collaborations with Healthcare
Tosha B. Wetterneck (2014)
Teaching Health-Care Operations in the MBA Program at Vanderbilt University Owen Graduate School of Management
Michael A. Lapré (2010)
Administration: 7 An Organizational Perspective
Mansour Mansour (2009)
Designing Safe Drug Names
B. Lambert (2005)
How do community pharmacies recover from e-prescription errors?
Olufunmilola Odukoya (2014)
Primary care physicians' perceptions of medication errors and error prevention in cooperation with community pharmacists.
Tuula Teinilä (2011)
VA CMOPs: producing a pattern of quality and efficiency in government.
Bernadette R Aragon (2012)
Dispensing Error Rate in a Highly Automated Mail‐Service Pharmacy Practice
J. Teagarden (2005)
The development of a next-generation human reliability analysis: Systems analysis for formal pharmaceutical human reliability (SAFPH)
Xi Zheng (2020)
Using Root Cause Analysis to Determine the System-Based Causes of Error
K. Wichman (2006)
Reducing dispensing errors in Swedish pharmacies: the impact of a barrier in the computer system
Annika nordén-hägg (2010)
Towards improving dose administration aid supply: a quality improvement intervention aimed at reducing dispensing errors
Julia Fiona-Maree (2013)
Patient Safety: A Nobody’s Concern
Abdul Kader Mohiuddin (2018)
Risk models to improve safety of dispensing high-alert medications in community pharmacies.
M. Cohen (2012)
Using Simulation to Improve First-Year Pharmacy Students’ Ability to Identify Medication Errors Involving the Top 100 Prescription Medications
Rabia S. Atayee (2016)
Medical Errors Prevention
Thomas Rodziewicz (2018)
Consumers' characteristics associated with the use of mail pharmacy services in the United States: Findings from the 2015 National Consumer Survey on the Medication Experience.
Mohamed Rashrash (2017)
An Image-based Approach for Drug Verification: An Initial Experience
Chun-Hung Cheng (2015)
The Iowa new practice model: Advancing technician roles to increase pharmacists' time to provide patient care services.
Michael Andreski (2018)
Effects of text enhancements on the differentiation performance of orthographically similar drug names.
C. Or (2014)
The Influence of Tall Man Lettering on Drug Name Confusion
R. Filik (2010)
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