International Journal of Research Foundation of Hospital and Healthcare Administration

Register      Login

VOLUME 7 , ISSUE 1 ( January-June, 2019 ) > List of Articles

Original Article

Healthcare Failure Mode and Effect Analysis: Dispensing Errors in the Pharmacy of an Outpatient Department of a Public Sector Tertiary-care Teaching Hospital

Rajat Prakash, Shashikant Sharma, Ashutosh Sharma

Keywords : Failure mode and effect analysis, Medication errors, Patient safety, Quality

Citation Information : Prakash R, Sharma S, Sharma A. Healthcare Failure Mode and Effect Analysis: Dispensing Errors in the Pharmacy of an Outpatient Department of a Public Sector Tertiary-care Teaching Hospital. Int J Res Foundation Hosp Healthc Adm 2019; 7 (1):11-18.

DOI: 10.5005/jp-journals-10035-1106

License: CC BY-NC 4.0

Published Online: 01-12-2018

Copyright Statement:  Copyright © 2019; The Author(s).


Background: Dispensing failures mean that a breach has occurred in one of the last safety links in the use of drugs. Although most failures do not harm patients, their existence suggests fragility in the process and indicates an increased risk of severe accidents. Materials and methods: To address these gaps in our understanding of dispensing errors, we conducted a direct observational study to determine the various failure modes, categorize the types of errors, and evaluate their potential to cause patient harm using healthcare failure mode and effect analysis (HFMEA). Results: The high-risk failure modes identified were as follows: patient unable to understand the prescription, illegible prescription, medication dispensed to wrong patient, counseling about new dose does not occur or ineffective, and patient taking incorrect dose. Conclusion: None of the steps in the drug-dispensing process were free of potential failure modes, but six failure modes emerged as the most vulnerable steps [with risk priority numbers (RPNs) over 168]. The most critical elements in the dispensing of drugs in the present setting were where patient does not understand proper use of prescription of potentially dangerous drug interaction (RPN 432) followed by illegible prescription. There is a dire need of application of systems theory with actions needed at every level of drug dispensing mechanism. Quality tools such as HFMEA and root cause analysis are warranted to forecast various failure modes and to find out root causes of adverse events that happen.

PDF Share
  1. James KL, Barlow D, McArtney R, et al. Incidence, type and causes of dispensing errors: a review of the literature. Int J Pharm Pract 2009;17(1):9–30.
  2. van den Bemt PMLA, Egberts ACG. Drug related problems: definitions and classification. Eur J Hosp Pharm Pract 2007;13:62–64.
  3. Beso A, Franklin BD, Barber N. The frequency and potential causes of dispensing errors in a hospital pharmacy. Pharm World Sci 2005;27(3):182–190. DOI: 10.1007/s11096-004-2270-8.
  4. Teagarden JR, Nagle B, Aubert RE, et al. Dispensing error rate in a highly automated mail-service pharmacy practice. Pharmacotherapy 2005;25(11):1629–1635. DOI: 10.1592/phco.2005.25.11.1629.
  5. Cina JL, Gandhi TK, Churchill W, et al. How many hospital pharmacy medication dispensing errors go undetected? Jt Comm J Qual Patient Saf 2006;32(2):73–80.
  6. Maviglia SM, Yoo JY, Franz C, et al. Cost-benefit analysis of a hospital pharmacy bar code solution. Arch Intern Med 2007;167(8):788–794. DOI: 10.1001/archinte.167.8.788.
  7. Chua SS, Wong IC, Edmondson H, et al. A feasibility study for recording of dispensing errors and near misses in four UK primary care pharmacies. Drug Saf 2003;26(11):803–813. DOI: 10.2165/00002018-200326110-00005.
  8. Rickrode GA, Williams-Lowe ME, Rippe JL, et al. Internal reporting system to improve a pharmacy's medication distribution process. Am J Health Syst Pharm 2007;64(11):1197–1202. DOI: 10.2146/ajhp060166.
  9. De Smet PA, Denneboom W, Kramers C, et al. A composite screening tool for medication reviews of outpatients: general issues with specific examples. Drugs Aging 2007;24(9):733–760. DOI: 10.2165/00002512-200724090-00003.
  10. Knudsen P, Herborg H, Mortensen AR, et al. Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. Qual Saf Health Care 2007;16(4):285–290. DOI: 10.1136/qshc.2006.022053.
  11. Teinila T, Gronroos V, Airaksinen M. A system approach to dispensing errors: a national study on perceptions of the Finnish community pharmacists. Pharm World Sci 2008;30(6):823–833. DOI: 10.1007/s11096-008-9233-4.
  12. Becker ML, Caspers PW, Kallewaard M, et al. Determinants of potential drug–drug interaction associated dispensing in community pharmacies in the Netherlands. Pharm World Sci 2007;29(2):51–57. DOI: 10.1007/s11096-006-9061-3.
  13. Malone DC, Abarca J, Skrepnek GH, et al. Pharmacist workload and pharmacy characteristics associated with the dispensing of potentially clinically important drug–drug interactions. Med Care 2007;45(5):456–462. DOI: 10.1097/01.mlr.0000257839.83765.07.
  14. Joint Commission Resources, Joint Commission International Failure Mode and Effects Analysis in Health Care: proactive risk reduction, 3rd ed.; 2010.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.