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Table 3 Details of nature and prevalence of dispensing errors in study hospitals

From: Nature of dispensing errors in selected hospitals providing free healthcare: a multi-center study in Sri Lanka

  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  
  1. Total number of dispensing errors in each category was used as denominator to calculate column percentage
  2. N Number of dispensing errors