Prevent Dispensing Error


Flynn E, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc. 2003;43:191–200.

UkensC. Deadly dispensing: an exclusive survey of Rx errors by pharmacists.  Drug Topics. March 13, 1997:100–11.

National Prescribing Centre


Institute for Safe Medication Practices (ISMP) (American)


Aronson & Richards. Oxford Handbook of Practical Drug Therapy. ISBN 0198530072


Fact of Dispensing Errors

  • 98.3% accuracy in dispensing medications
  • Therefore, 1.7% inaccuracy rate
  • Over 3 billion medications dispensed per year
  • 4 errors per day per 250 prescriptions filled
  • Over 51 million dispensing errors per years

Category of Errors

  • Misreading the prescription
  • Incorrect picking of the medicines
  • Labelling the medicine wrongly
  • Giving the wrong prescription to the wrong patient
  • Extract of the wrong strength
  • Incorrect compounding
  • Supplying contaminated / out-of-date stock

Most Prevalent Dispensing Error

The top three dispensing errors include (1) dispensing an incorrect medication, dosage strength, or dosage form, (2) dosage miscalculations, and (3) failure to identify drug interactions or contraindications.

Common Causes Dispensing Errors

1. Workload

Solve –>

  • Ensure staffing levels
  • Limiting workload with :
  1. Dispense ≤ 150 prescription per pharmacist per day
  2. Require rest breaks every 2-3 hours
  3. Warm up before restarting work task
  4. Require 30 minute meal break

2. Distraction

Solve –>

  • Traine support personnel to answer telephone

3. Work Area

Solve –>

  • Label on Bins and Shelves à Using barcodes to reduce errors
  • Separate by route of administration
  • Use auxiliary label
  • Use unconventional type font to enhance reading of drug name
  • Separate sound-alike/look-alike drug

Avoiding Dispensing Errors

  • Patient knowledge
  • Have a therapeutic goal
  • Knowledge about the drug
  • Monitor effect and adverse effect
  • Good communication

Minimize Dispensing Errors

  • Use mnemonic “HELP” when making final check

H  = “How Much” has been dispensed

E  = “Expiry Date” check

L  = “Label” for correct patient’s name

P  = “Product

Maximize Dispensing Accuracy

  1. Lock up drugs that could cause disastrous errors
  2. Develop and implement procedures for drug storage
  3. Reduce distractions, design a safe dispensing environment, and maintain optimum workflow
  4. Use reminders such as labels and computer notes to prevent mix-ups between look-alike and sound-alike drug names
  5. Keep the original prescription order, label, and medication container together throughout the dispensing process
  6. Compare the contents of the medication container with the information on the prescription
  7. Enter the drug’s identification code into the computer and on the prescription label
  8. Perform a final check on the prescription, the prescription label, and manufacturer’s container; when possible, use automation (e.g., bar coding)
  9. Perform a final check on the contents of prescription containers
  10. Provide patient counseling

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