An Exploration into the Reduction of Pharmacy Dispensing Errors

This report investigates the reduction of pharmacy dispensing errors, a critical issue in healthcare. It begins with an abstract defining dispensing errors and their impact on patient safety, emphasizing the discrepancy between prescriptions and dispensed medications. The report employs a qualitative research methodology to gain in-depth knowledge on minimizing medication errors. It includes a feasibility study highlighting the importance of financial resources. The study's impact section underscores the significance of accurate medication delivery, packaging, and clear communication for sustaining brand image and promoting community health. The report is structured with formative and summative assessments, research questions, a literature review examining the causes and effects of dispensing errors, and a detailed methodology section. The methodology includes primary and secondary data collection methods, along with a discussion of qualitative and quantitative approaches. Ethical considerations and study limitations are also addressed. The report concludes with a feasibility study and an impact analysis, emphasizing the importance of correct medication delivery and its effect on patient outcomes. The report aims to provide a comprehensive understanding of the issue and strategies for improvement.

EXPLORATION INTO THE
REDUCTION OF
PHARMACY DISPENSING
ERRORS

ABSTRACT
Dispensing error is referred to as the difference between the prescription provided and the
medicine being provided to the patient. This is majorly because of the reason that when there
will be difference between the prescription and the medicine provided then this will create
problem in managing the health and safety of the person. Dispensing error is mainly referred to
as the range of discrepancy which is linked with the prescription and also the medicines which in
turn has been delivered to the patient by the pharmacy on the key basis of prescription. With the
help of the methodology section it was seen that the method for the study chosen was the
qualitative research as the researcher anted to gain in- depth knowledge relating to the research
topic that is how medication reduces dispensing error. Further, with the help of the feasibility
study it was seen that finance was the major resource necessary for the success of the research.
With the study of impact it was seen that if country and medical health care providers use right
medicine of desired quality and also deliver the same to correct time, with right dose, strength
and frequency in both verbal and written format with appropriate packaging will help to sustain
the brand image of the country and provides healthy community as well.

Table of Contents
Formative Assessment.....................................................................................................................4
Research question: ..........................................................................................................................4
INTRODUCTION...........................................................................................................................4
Background/ literature review..........................................................................................................4
Aim and objective of research.........................................................................................................5
Research aim: ..............................................................................................................................5
Research objectives: ....................................................................................................................5
Possible Methodology......................................................................................................................6
Potential resources and timeline......................................................................................................6
Summative Assessment...................................................................................................................9
INTRODUCTION...........................................................................................................................9
Research objectives: ....................................................................................................................9
Research question: ......................................................................................................................9
LITERATURE REVIEW..............................................................................................................10
METHODOLOGY........................................................................................................................14
A) Aims and objectives..............................................................................................................14
B) Study design and development.............................................................................................15
C) Study population...................................................................................................................15
D) Data management to include collection and storage and analysis........................................16
E) Study limitation.....................................................................................................................16
F) Ethical issues and their migration.........................................................................................17
FEASIBILITY STUDY- RESOURCES AND BUDGETARY CONSIDERATION...................17
IMPACT........................................................................................................................................19
REFERENCES..............................................................................................................................22

Research Title:
An Exploration into the reduction of Pharmacy dispensing Errors
Formative Assessment
Research question:
How pharmacy can minimise the errors in medication.
Rationale- the major reason behind the selection of the research topic of ‘how pharmacy can
minimise the errors in medication is that in the current modern world there are many different
types of errors taking place in the medication of the people. Thus, this research will assist in
managing the various ways in which the company or the health care setup in managing the health
and medication of the patients coming to the place.
INTRODUCTION
Dispensing medicine define as a method of giving medicating to the patient along with
providing them knowledge related to the drugs as well as showings them the dose for patient
safety and health. For reducing the dispensing error United Kingdom is maintaining a ward
pharmacy system. In this research, aim and objective is going to be formulated so that the whole
investigation can be done in a systematic manner. It has been said that United States National
Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) says that a
medication issue refers to “any preventable event which might create inappropriate medication
use as well as patient might get harm at the time of medication in the control of health care
professional, consumer as well as patient. Such events may be associates to the professional
practice, health care procedures, products and systems, consist of prescribing, order
communication, packaging, and nomenclature, dispensing, distribution, education, monitoring as
well as use” Also this research includes various authors view point and for which literature
review section is going to be developed.
Background/ literature review
As per the views of McDerby and et.al, (2019) dispensing error is defined as the
discrepancy or the inconsistency which is present between the medicine prescribed and the
medicine which is being delivered to the patient. This is the error which need to be taken care as
if there will be more error then this will have a great impact over the treatment and the
medication of the patient and this can also impact the recovery of the patient.

Along with this Lloyd and et.al, (2016) argues that for proper working and caring of the
patient the most essential thing is that the pharmacist must have proper knowledge relating to the
adverse effect which may take place at time of managing the prescription and the medicines of
patients. This is particularly because of the fact that is the person dealing in medicine does not
know the effect of any drug and they give it to the patient who is not prescribed of that then this
can have very bad effect over the health of the patients.
In addition to this Stewart and et.al, (2018) articulates that the management of the drug
and its usage for the person or the patient is very essential to have the knowledge. Thus, if the
person or the pharmacist are having proper knowledge relating to the use of the drugs. This is
helpful as if the person is having proper knowledge relating to the fact that when to use which
drug then there will not be any of the error and this will have good and positive impact over the
patient and will result in healthy recovery of the patient.
Along with this Wheeler and et.al, (2018) states that when the people dealing in drug and
the different medicines then this will have a great impact over the effect of the consumption of
the drug. It is the responsibility of the person to gain all the knowledge relating to the drug usage
and consumption and also to gain the knowledge relating to the effect of the consumption of the
drug and what will happen if the drug dosage is increased without seeking permission of the
doctor or the medical practitioner.
Aim and objective of research
Research aim:
 To know the basic concept about dispensing errors.
 To evaluate the dispensing error pharmacist awareness about all kind of adverse effect. To avoid the drug interaction and its adverse side effect
Research objectives:
 What is the meaning of dispensing errors?
 How to understand dispensing error pharmacist awareness about all kind of adverse
effect.
 How to avoid the drug interaction and its adverse side effect?

Possible Methodology
This is one of the main section for every research where best and most suitable method used
by the researcher for collecting information and data related to the topic. There are various
techniques which are going to be discussed as follows:
Primary and secondary data collection method
In context of gathering primary information, it is said that researcher adopt questionnaire
method where by using online mode of filling questionnaire is used due to COVID 19. On the
other hand, in case of secondary method, literature review is the method used by investigator
where view point of different authors analysed by the researcher.
Qualitative and quantitative approach
There are two main approaches for gathering information where one is qualitative is
completely based on human perception and includes all the data which are non- numerical in
form. On the other hand, in case of quantitative method, data collected by investigators are in
number form where graph, figures and statistical data are included. In this research, investigators
adopt quantitative method for collecting all the information and data.
Potential resources and timeline
The potential resources which are essential for the completion of the research is of
various types like the internet, computer, laptops, transportation, stationery, personal
expenditure, communication cost and many other different types of resources and other
instruments and material. All these resources are very essential for the researcher to make use as
this will assist the researcher in making the research successful.

Summative Assessment
INTRODUCTION
Dispensing error is considered to be as an effective set of discrepancy associated with the
prescription and also the medicines which in turn has been delivered to the patient on the key
basis of prescription. The dispensing in turn tends to mainly comprise of the dispensing of the
medicine which in turn is highly inferior associated with the information quality and
pharmaceutical (Shawahna and et.al., 2016). Such key practice is mainly linked with the
professional practice, products and systems, health care procedures, prescription, communication
of the order, packaging, nomenclature, distribution, dispensing, education and monitoring. The
most common type of the dispensing error is mainly linked with the dispensing of the wrong
drug, wrong quantity, omission of the items and wrong strength. This study will highlight on
effectively examining how the pharmacy can minimize the key errors related with the medication
section. This study tends to mainly focus on exploring the reduction within the pharmacy related
with the pharmacy dispensing errors.
Research aim: “An Exploration into the reduction of Pharmacy dispensing Errors.”
Research objectives:
 To know the basic concept about dispensing errors.
 To evaluate the dispensing error pharmacist awareness about all kind of adverse effect. To avoid the drug interaction and its adverse side effect
Research question:
 What is the meaning of dispensing errors?
 How to understand dispensing error pharmacist awareness about all kind of adverse
effect.
 How to avoid the drug interaction and its adverse side effect?
 How pharmacy can minimise the errors in medication?
Rationale
The key significant reason related with carrying out the study is that it is considered to be
as one of the key issue currently. It is considered to be highly important to effectively evaluate
the key significant measures and factors which helps in reducing such dispensing errors within
the pharmacy. Another key prominent reason for carrying out the study is mainly linked with the
academic as well as for the personal interest of the researcher.

Research significance
This study is highly significant for the pharmacy industry because it will help them in
taking necessary set of precautionary measures which helps in the reduction of dispensing errors.
This study is highly useful for the researcher further because it helps in effectively improving the
results and investigation. This will help the researcher for effectively further carrying out the
study and helps in the better attainment of the key relevant results by bridging up the gaps.
LITERATURE REVIEW
Theme 1: To know the basic concept about dispensing errors.
Aldhwaihi and et.al., (2016) sought to determine the fact that, the medication errors tend
to have high degree of impact upon the safety of the patient. Such errors can occur at various
stages which mainly includes ordering, dispensing, prescription and administration. The
detection of such errors is highly useful in effectively encouraging the safe culture. Effective
implementation of the tailored preventive strategies is highly significant in effectively improving
the set degree of results and outcomes. The major type of the pharmacy dispensing error is
mainly linked with the dispensing of the wrong drug, wrong quantity, omission of the items and
wrong strength. Tseng and et.al., (2018) argued that, the medication errors are considered to be
high when at the time of prescription and the ordering stage which is further followed up by the
administration stage. Medication and dispensing errors are the key leading cause of the mortality
and morbidity of the patient. However, the faulty dispensing can eventually lead to the litigation
which is considered to be highly expensive and also results in the increased degree of cost. The
dispensing error is highly traumatic for the patient as well as for the pharmacist. The dispensing
error is mainly associated with the deviation associated with the prescription order and
inadequate labelling. The error which has been committed by the individual is mainly the result
of the error prone process and system. Implementation of the system oriented approach or
strategy is considered to be highly prominent in minimization of the dispensing errors.
Subsequently, AL-WorafiI, (2018) stated the point that, errors are considered to be as the
failure or near misses within the process and the system. The appropriate set of clinical check
and also the final accuracy check related with the medical item is considered to be of key
relevance importance. The pharmacies tend to dispense high volume of medications which
results in the high degree of dispensing errors. There can be prescribing faults, transcription
error, prescription error and administration error. Incorrect dosage form, incorrect name of the

patient, incorrect expiry date of the medication, dispensing at the wrong time, omission of
warning associated with medication, incorrect drug name, failure to dispense, inferior quality
medicine, etc. are considered to be the key dispensing errors which has been conducted by the
pharmacy company. However, the dispensing errors likely affect the health of the patient.
Aldhwaihi and et.al., (2016) sought to determine the fact that, the dispensing issue is
mainly linked with the inappropriate degree of medication which has severe impact on the health
of the patient. The United Kingdom tends to focus on prominently complying with the ward
pharmacy system which is useful in effectively reducing the human error. However, dispensing
of the medication is mainly linked with the procedure of giving the prescribed drug to the named
person upon the basis of the prescription. This is relevant in avoiding and reduction within the
dispensing errors and carry out effective practice within the pharmacy with utmost level of
accuracy and relevance. It is important for the pharmacy company to maintain complete set of
records and work in a highly responsible manner at the time of dispensing of medicine to the
prescribed person. This way it helps in improving the health outcomes and results.
Theme 2: Dispensing error which pharmacist should be aware
Weir, Newham and Bennie (2020) stated that mistakes are a part of every human activity
including health care and that is why, there is a need to take proper care of the error so that
health of patients are properly managed. Generally, in every country, some of the error are
happen in every 1 out of 5 dispensers. Such that medicine with similar names or packaging are
consider one of the top common issue, when working in a busy dispensary, medicine with same
name or almost identical packaging confused the workers. Hence, more that 70% of the error
report received due to this issue. Abdel-Qader and et.al., (2020) also support and state that some
medicine is vulnerable to mix-up due to their names i.e. enalapril and anafranil, while on the
other side, same got confused due to its packaging like amlodipine and allopurinol, hence these
are easy target for a dispensing error. So there is a need to be focused upon this issue because it
may somehow cause serious consequence. For example, a case in UK, when prednisolone was
mixed up with fliclazide due to similar packaging and as a result, patient going into a diabetic
coma.
Campbell and et.al., (2018) present their own views and stated that dispensing out of date
medicine is also consider another dispensary error which pharmacist should be aware. Such that
it is most common error which also cause negative impact upon patient's health. For example, if

patient had an infection and then looks at packaging, then government may take a change against
them. That is why, there is a need to minimize the error otherwise it may leads to cause wrong
impact upon project. Hence, the quality of all pharmacy care activities should be assured by
pharmacist and correct a prescribing error before dispensing. Rodriguez‐Gonzalez and et.al.,
(2019) explain that incorrect calculation is also consider another error which is also perform by
pharmacist because a complex calculation is fertile ground for an error. As sometimes
pharmacist get confused in relation to milligrams and milliliter, thus it is necessary to pay
attention especially in the case of children because a small mistake in calculation will lead to
cause serious issue and also affect the overall image of the organization as well.
Therefore, the root cause of dispensing error is due to poor, often unreadable,
handwriting and lack of effective controls which leads to interruption. Many secondary research
also stated that due to dispensing the wrong drug with wrong quantity by inexperience staff is
affect the patient's life in negative manner. Naybour, Remenyte-Prescott and Boyd (2019)
present their own views and stated that sometimes due to urgency, misreading prescription is
another type of dispensing error that leads to cause negative impact upon the results. As
everyone knows. That doctor with near illegible handwriting and dispensary are only guess but
sometime due to misreading prescription, wrong medicine is prescribing. Author also stated that
pharmacist can misread the drug name and also Latin abbreviation and this leave a scope for
some error. Therefore, it is not good to only guess the handwriting of doctors and provide
medicine accordingly, but there is a need to make sure that read the prescription in better manner
and then offer medicine so that it will not cause any negative cause to an individual's health.
Many studies also are identified the factor behind causing the dispensing error and
revealed that most of the pharmacist assistant followed by the high workload and these errors
should be reducing immediately because it somehow leads to cause negative impact upon
patient's health. On the other side, AL-WorafiI (2018) argued that pharmacy design, interruption
and other pharmacy environmental factors are also plays an important role in order to increase
the incidence of dispensing error. Thus, a culture within hospital should be positive so that all the
employees will be happy and they also realize the work related responsibilities which in turn
leads to improve the results in better manner. Also, all the pharmacist who work of dispensing
should be concentrate on their work and this in turn leads to minimize the error up to some level
and hence, provide appropriate medicine to the patients as well.