Near-miss dispensing errors in Japanese community pharmacies: error types and associated factors across dispensing stages.

Abstract

Introduction: The types and causes of dispensing errors vary across the stages of the complex dispensing process in community pharmacies. Notably, the analysis of near-miss reports may facilitate improvements in healthcare environments and operational practices.

Aim: We aimed to identify the characteristics of the factors contributing to near-miss errors at each stage of the dispensing process and to determine which factors require priority action.

Method: We conducted a secondary analysis of near-miss dispensing errors voluntarily reported by community pharmacies through the near-miss reporting system of the Japan Council for Quality Health Care. The associations between various types of near-miss errors and their contributing factors were estimated using multivariate logistic regression models.

Results: Among the 45,483 near-miss incidents, most were reported during the dispensing and accuracy-checking stages (n = 35,384, 77.8%). At the prescription data entry stage, near-miss errors were primarily associated with the usability of computer systems and look-alike/sound-alike (LASA) drug names. At the dispensing and accuracy-checking stage, the characteristic contributing factors included LASA drug names and similar appearances, patient preferences for brand name/generic, user-friendliness of equipment, and human factors among pharmacists. During the medicine supply stage, factors associated with inadequate confirmation of the patient's understanding were identified. Finally, at the post-supply stage, patient-related factors and insufficient communication were identified as key contributors.

Conclusion: Based on the reported near-miss events, priority actions are required to address LASA drug names and similar appearances, generic prescription systems, labour-intensive dispensing practices, the usability of computer systems and equipment, and inadequate communication with patients.