Table 3 Details of nature and prevalence of dispensing errors in study hospitals
Example | SH1 (N=1010) | SH2 (N=400) | SH3 (N=410) | Total (N=1849) | Error for each medication dispensed | |
|---|---|---|---|---|---|---|
Labelling errors | ||||||
Duration of medications not indicated on dispensing label | Diclofenac sodium tablets 50 mg bd for 3 days was prescribed. Six tablets were dispensed with directions to be used (one tablet two times per day) but without indicating that the treatment should continue for 3 days. | 966 | 379 | 413 | 1758 | 1758/1849 = 0.95 |
Total quantity of medication dispensed not indicated on dispensing label | 84 tablets of metformin (500 mg tds for 4/52) was dispensed without indicating the total number of tablets (84) on the dispensing label. 56 beclomethesome capsules (400 microgram BD 01 month) was dispensed without indicating the total number of capsules as 56 on the dispensing label. | 958 | 216 | 416 | 1590 | 1590/1849 = 0.86 |
Dosage form is not indicated on dispensing label | Dispensed amoxicillin 125 mg chewable tablets and indicated amoxicillin 125 mg instead of amoxicillin 125 mg chewable tablets on the dispensing label | 777 | 221 | 286 | 1284 | 1284/1849 = 0.69 |
Incorrect or incomplete medicine strength on dispensing label | Indicated thyroxin 50 mg instead of 50 micrograms on dispensing label | 906 | 96 | 278 | 1280 | 1280/1849 = 0.69 |
Medicine strength not indicated on dispensing label | Prescribed aspirin 75 mg nocte and dispensed 28 tablets of aspirin 75 mg tablets in dispensing label indicating only ‘aspirin 01 at night’ instead of ‘aspirin 75 mg take 01 tablet at night’ | 907 | 61 | 284 | 1252 | 1252/1849 = 0.68 |
Incorrect or incomplete medicine name (using unapproved abbreviations) on dispensing label | Indicating paracetamol as PCM, carbamazepine as CBZ on dispensing label | 508 | 221 | 288 | 1017 | 1017/1849 = 0.55 |
Medicine name not indicated on dispensing label (neither generic nor brand) | Verapamil 40 mg tds was prescribed and 84 tablets of verapamil was dispensed with directions to be used, but without indicating the medication name on the dispensing label Was commonly observed with paracetamol and chlorpheniramine as well | 514 | 34 | 198 | 746 | 746/1849 = 0.40 |
Incorrect or incomplete dosage form on dispensing label | Indicating ISMN 60 mg only instead of ISMN 60 mg SR tablet on dispensing label | 233 | 179 | 153 | 565 | 565/1849 = 0.31 |
Special instructions not provided where necessary | Instruction of ‘Take at least half an hour before food’ was not on the dispensing label for omeprazole. Swallow whole (Do not crush or chew) for enteric coated tablets such as erythromycin and omeprazole was absent. | 241 | 117 | 151 | 509 | 509/1849 = 0.28 |
Failing to attach auxiliary labels | Additional labels of “Shake the bottle” and “Store in refrigerator” was not attached to reconstituted cephalexin syrup container (Cephalexin was reconstituted in bulk and the required volume was dispensed in a different container without original label indicating these information) | 127 | 83 | 73 | 283 | 283/1849 = 0.15 |
No label with dispensed medicine | Paracetamol 2 tbs SOS was prescribed and 20 paracetamol tablets were dispensed in an envelope with no written information on the envelope. Same was observed with salbutamol and beclomethasone capsules. Insulin 12 IU mane and 10 IU nocte was prescribed and 1 vial of insulin has dispensed in a container without a dispensing label. | - | 21 | 153 | 174 | 174/1849 = 0.09 |
Dosing intervals and frequency not indicated on dispensing label | Paracetamol two tablets’ written instead of ‘paracetamol two tablets to be taken every 6 hrly Dry powder capsules of salbutamol and beclamethasone as prescribed as 1 capsule bd and it was dispensed to patients without any dosing interval or frequency of administration Was not with dry powder capsules of salbutamol (Asthelin) | 09 | 16 | 40 | 65 | 65/1849 = 0.04 |
Total | 6146 | 1644 | 2733 | 10523 (63.1%) | ||
Concomitant errors | ||||||
Medicine name, route, dosage form not indicated in prescription but ignored by pharmacist | Losartan 1 bd was written instead of losartan 50 mg tablet bd for 1/12 | 922 | 381 | 418 | 1721 | 1721/1849 = 0.93 |
Prescriber not identified in prescription but ignored by pharmacist | - | 918 | 316 | 422 | 1656 | 1656/1849 = 0.90 |
Clinically significant drug interactions on prescription missed by pharmacist | Medicines have been dispensed without detecting the drug-drug interactions (Table 4) in the prescription Eg: Both enalapril and spironolactone were prescribed together and the interaction was not detected by the pharmacist. Both medicines were dispensed to be used together | 38 | 26 | 18 | 82 | 82/1849 = 0.04 |
Patient name and age not indicated in prescription but ignored by pharmacist | - | - | 48 | - | 48 | 48/1849 = 0.03 |
Total | 1878 | 771 | 858 | 3507 (21.0%) | ||
Documentation errors | ||||||
Pharmacist who dispensed the medications were not indicated on label | - | 948 | 400 | 424 | 1772 | 1772/1849 = 0.96 |
Total | 948 | 400 | 424 | 1772 (10.6%) | ||
Content errors | ||||||
Wrong number of units | Issuing 31 tablets of atorvastatin 10 mg instead of 28 tablets (03 tables were issued in excess) | 462 | 78 | 139 | 679 | 679/1849 = 0.37 |
Wrong dosage form | Dispensing a slow release form of ISMN 60 mg SR instead of normal release ISMN 30 mg. (Patient was advised to crush it and take the half from ISMN 60 mg SR) | 15 | 07 | 44 | 66 | 66/1849 = 0.04 |
Wrong strength | Dispensing of hydrochlorothiazide 25 mg tablets instead of 50 mg when prescribed as 1 tablet in the prescription | - | 02 | 60 | 62 | 62/1849 = 0.03 |
Wrong medications | Dispensing of famotidine instead of omeprazole at verbal request of the prescriber but not corrected in the prescription | - | - | 05 | 05 | 05/1849 = 0.003 |
Medication omissions | [No errors detected] | - | - | - | - | |
Deteriorated medicine | [No errors detected] | - | - | - | - | |
Total | 477 | 87 | 248 | 812 (4.9%) | ||
Other errors | ||||||
Medications dispensed in unsuitable packaging | Glyceryl trinitrate (GTN) and thyroxin were dispensed in a container without light protection | 06 | 08 | 60 | 74 | 74/1849 = 0.04 |
Medications dispensed to wrong patient | Patient was found carrying medications which were left behind in the counter by the previous patient | - | 01 | - | 1 | 01/1849 = 0.0005 |
Total | 06 | 09 | 60 | 75 (0.4%) | ||
9455 | 2911 | 4323 | 16689 | |||