Published
2026-01-08
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Pharmacy Practice & Practice-Based Research
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Copyright (c) 2026 Jamie Alivio, Stephanie Wai Khuan Teoh, Nabeelah Mukadam
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright of content published in INNOVATIONS in pharmacy belongs to the author(s).
The road to safer dispensing: Evaluation of dispensary final check of dispensed medicines in a hospital dispensary
Jamie Alivio
Curtin University, Western Australia
https://orcid.org/0009-0004-5774-9597
Stephanie Wai Khuan Teoh
King Edward Memorial Hospital
https://orcid.org/0000-0003-2763-1163
Nabeelah Mukadam
Pharmacy Department King Edward Memorial Hospital 374 Bagot Road, Subiaco, Perth, Western Australia 6008
DOI: https://doi.org/10.24926/iip.v16i4.6848
Keywords: pharmacy, dispensing, medication error, medication safety
Abstract
Aims: This study aims to evaluate dispensing errors identified in final check of dispensed medications recorded and identify potential trend over a twelve-month period, to compare the common type and prevalence of the near miss involved in the dispensing error and to obtain institution specific error for future staff education.
Methods: Research Electronic Data Capture (REDCap) database was used to collect errors identified in the final check of dispensed medicines daily in the study hospital. Over a 12-month period between January 2023 and December 2023, dispensary staff recorded errors in an online form on the database.
Results: A total of 98 entries were recorded in REDCap database over the 12-month period, which included 106 errors. During this time, 38,781 medications were dispensed through i.Pharmacy dispensing system. The cumulative rate of dispensing error in 2023 was 0.27%. The highest rates of dispensing errors were recorded in August and October 2023. Over 3,400 items were dispensed in each month, which is comparatively higher than other months. Four errors contributed to 66.04% of all errors identified: incorrect instructions (n=27, 25.47%), other (n=16, 15.09%), incorrect quantity dispensed (n=15, 14.15%) and incorrect quantity packed (n=12, 11.32%).
Conclusion: The reporting and learning system enabled the identification and analysis of the type of dispensing errors in the dispensary. The analysis promotes reflective learning to prevent repeating similar dispensing errors. It also enables targeted education for staff members which is valuable in improving medication safety.
