Prospective systemic risk analysis of the dispensing process in German community pharmacies

Medicine dispensing represents an error-prone activity, carrying a considerable risk for patients.

To prospectively identify and prioritize potential failure modes in the medicine dispensing process as well as to develop corrective actions for patient safety improvement in German community pharmacies.

Failure mode and effects analysis was performed in 2 community pharmacies in North Rhine-Westphalia, Germany, in October 2016. A 9-member team was assembled, comprising of a leader and process experts who prospectively assessed the medicine dispensing process by brainstorming, quantified the attributed risks, proposed corrective actions, and reassessed the risks.

The analysis identified 39 failure modes, out of which the highest criticality scores were assigned to inadequate assessment of therapy appropriateness (Risk Priority Number 45), reluctance to deviate from rebate contracts (36), and dispensing the wrong medicine (30). The corrective actions proposed demonstrated a considerable potential for risk reduction in most failure modes, the most effective of which were introducing obligatory continuous education for pharmacists, organizing communication training, and implementing electronic prescribing.

This analysis not only detected various potential safety issues concerning the dispensing in Germany but also strongly indicated that application of failure mode and effects analysis could be highly effective in prospective risk reduction in community pharmacies.