Evaluation of Medication Errors in Community Pharmacy Settings: A Retrospective Report

Background. Drug-related errors can compromise patient care, increase health care costs, and, in worst case scenarios, result in patient deaths. Objective. To evaluate the incidence and contributing factors of medication dispensing errors in community pharmacy settings reported to the New Hampshire Board of Pharmacy (NHBOP). Methods. Medication errors reported to the NHBOP from February 1, 2007, to July 31, 2012, in a community pharmacy setting were reviewed. Quality Related Event Report (QRER), a standardized form developed by the NHBOP, was used to record the errors. The QRER allows collection of information related to the error, including time, date, type of error, and contributing environmental factors. Results. There were a total of 68 reported errors. The majority of errors (40%) involved dispensing an incorrect medication; 31% involved incorrect doses, and 12% involved incorrect directions. A majority of the errors involved new prescriptions (78%); 51% occurred during the pharmacist final check stage and 26% occurred during the data entry phase of the initial processing of the prescription. A greater percentage of errors (68%) occurred when only 1 pharmacist was on duty versus 29% with 2 pharmacists on duty. Conclusions. Contributing factors for errors included high prescription volumes and lack of adequate pharmacist coverage. Increasing pharmacist overlap hours in stores with high prescription volumes and implementing a formal technician certification program to ensure the consistency in training quality could assist in decreasing medication errors and improving patient safety.