Dispensing-label errors in hospital: types and potential causes.
OBJECTIVE
The aim was to evaluate the potential causes of dispensing-label errors at a hospital.


METHODS
The study took place at a 1200-bed NHS Foundation Trust with two main pharmacy dispensaries (one manual and one automated). Face-to-face interviews were conducted with staff involved in label-generation errors to obtain in-depth understanding of dispensing-label errors. Interviews were tape-recorded, transcribed and analysed with the aid of Nvivo into themes.


RESULTS
Factors suggested as causing label-generation errors were illegible handwriting, lack of knowledge, hurrying through tasks, distractions, interruptions and the use of past medical records in generating labels. Self-checking every stage of the labelling process was suggested as the key to detecting and preventing errors.


CONCLUSIONS
The study highlights the vulnerability of the label-generation process to errors, with potential causes linked to organisational, environmental, task, team and individual factors.
Anto
Berko
B
Department of Pharmacy, King's College London, London, UK.
Barlow
David
D
Oborne
Alice
A
Cape
Angela
A
Vlassoff
Anya
A
Whittlesea
Cate
C
D004348:Drug Labeling / Q000592:standards*; D006801:Humans; D008131:London; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008510:Medication Systems, Hospital / Q000458:organization & administration; D004364:Pharmaceutical Preparations / Q000008:administration & dosage; D010595:Pharmacists / Q000458:organization & administration / Q000592:standards*; D010607:Pharmacy Service, Hospital / Q000592:standards / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care / Q000379:methods
D004364:Pharmaceutical Preparations