Medication Errors
An analysis of the cognitive and evnironmental factors underlying accurate dispensing behaviours in hospital, ward and community pharmacies
Dr Amy Irwin, a.irwin@abdn.ac.uk, Dr Kathryn Mearns & Dr Margaret Watson
Medication error is estimated to cost the NHS in excess of 300 million a year in associated expenditure, including: prolonged hospital stays, legal claims and readmissions to hospital. The process of dispensing medication to the patient is estimated to account for approximately 17.8% of medication error rates in the UK, based on reports to the National Patient Safety Agency reporting and learning system. The current research project funded by the Scottish Funding Council (2009-11) aims to look at the issue of dispensing error from a cognitive perspective. The work will encompass an analysis of dispensing practices in hospital and community pharmacies together with dispensing on hospital wards. An improved understanding of the situational and cognitive factors underlying dispensing error is vital in order to reduce error rates and improve patient safety. The current project will therefore examine the dispensing process using a mixed methods approach, potentially including: computer based simulations, task analysis, simulation studies, interviews and qualitative questionnaires. To date one computer simulation study examining drug selection accuracy has been carried out to completion. The results suggest that orthographic similarity between drug names can negatively affect accurate drug selection, with a significantly greater effect seen when more than one similar drug name is present within the same visual field as the target drug.