Preventing medication errors in community pharmacy: root-cause analysis of transcription errors

BACKGROUND: Medication errors can have serious consequences for patients, and medication safety is essential to pharmaceutical care. Insight is needed into the vulnerability of the working process at community pharmacies to identify what causes error incidents, so that the system can be improved to enhance patient safety. METHODS: 40 randomly selected Danish community pharmacies collected data on medication errors. Cases that reached patients were analysed, and the most serious cases were selected for root-cause analyses by an interdisciplinary analysis team. RESULTS: 401 cases had reached patients and a substantial number of them had possible clinical significance. Most of these errors were made in the transcription stage, and the most serious were errors in strength and dosage. The analysis team identified four root causes: handwritten prescriptions; "traps" such as similarities in packaging or names, or strength and dosage stated in misleading ways; lack of effective control of prescription label and medicine; and lack of concentration caused by interruptions. CONCLUSION: A substantial number of the medication errors identified at pharmacies that reach patients have possible clinical significance. Root-cause analysis shows potential for identifying the underlying causes of the incidents and for providing a basis for action to improve patient safety.