title: Preventing medication errors in community pharmacy: root-cause analysis of transcription errors.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors: Pharmakon, Danish College of Pharmacy Practice, Hillerød, Denmark. pkn@pharmakon.dk
authors: P
authors: P
authors: Knudsen
authors: H
authors: H
authors: Herborg
authors: A R
authors: AR
authors: Mortensen
authors: M
authors: M
authors: Knudsen
authors: A
authors: A
authors: Hellebek
mesh_terms: D015984:Causality; D003718:Denmark / Q000453:epidemiology; D004349:Drug Packaging / Q000592:standards; D011307:Drug Prescriptions; D006801:Humans; D015994:Incidence; D008499:Medical Records / Q000592:standards*; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D010594:Pharmacies / Q000592:standards*; D017751:Safety Management; D013597:Systems Analysis
references: Ugeskr Laeger. 2001 Sep 24;163(39):5361-4
references: 11590950
references: Drugs. 2005;65(13):1735-46
references: 16114974
references: Drug Saf. 1996 Nov;15(5):303-10
references: 8941492
references: Drug Saf. 2003;26(11):803-13
references: 12908849
references: Qual Saf Health Care. 2007 Aug;16(4):291-6
references: 17693678
references: J Am Pharm Assoc (Wash). 2003 Mar-Apr;43(2):191-200
references: 12688437
references: BMJ. 2000 Mar 18;320(7237):768-70
references: 10720363
references: Fam Pract. 2003 Jun;20(3):231-6
references: 12738689
references: Am J Nurs. 2005 Mar;105(3 Suppl):14-24; quiz 48-51
references: 15802994
references: Drug Saf. 2005;28(6):495-512
references: 15924503