Dispensing Errors Lead Incident Reports


Most common errors include incorrect drugs and strength.

Pills and X

A new report from the UK’s National Pharmacy Association shows that the two most common errors reported were dispensing for a wrong/drug/medicine and dispensing the wrong strength.

The data from the Scotland Patient Safety Incident report notes, “It is concerning to see certain error types continuing to occur despite being well publicized and highlighted in previous reports…”

The most common errors reported from October 2018 to March 2019 included:

  • Wrong drug/medicine: 32 percent

  • Wrong strength: 23 percent

  • Mismatching between patient and medication: 19 percent

  • Medicine compliance aids: 13 percent

  • Deliveries: 10 percent

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Contributing factors for errors:

  • Untidy shelves

  • Replacing split strips of tablets into open boxes of the wrong strength

  • Self-checking prescriptions

  • Same surname, different addresses bagged together on a shelf, the address on each prescription bag collected was not confirmed with the patient 

  • Different surname, same forename picked by pharmacy staff on patient collection

  • Additional bags labels becoming attached to different prescription bags in the awaiting delivery box

  • The error rate for low harm was 10 percent, and moderate harm was 6 percent.


Wrong strength incidents included: 

  • Fluticasone 125/5 inhaler for 250/5

  • Gabapentin 100mg for 300mg 

  • Metformin 850mg for 500mmg

  • Mirtazapine 15mg for 45mg

  • Pregabalin 50mg for 150mg

  • Ramipril 5mg for 2.5mg

  • Zopiclone 3.75mg for 7.5mg


The most common factor, accounting for 58% was Task factors (this includes work guidelines/procedures/policies, availability of decision-making aids). 


Tips identified in the report:

  • Address any safety issues identified – carry out a root-cause analysis to determine the cause(s) and take steps to prevent any reoccurrence.

  • Conduct safety huddles and staff meetings.

  • Create a patient safety notice board in the dispensary where behaviors to avoid repeating recent errors can be highlighted.

  • Implement a “just” culture which focuses on learning, rather than blame.
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