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Reducing dispensing errors in Swedish pharmacies: the impact of a barrier in the computer system
  1. Annika Nordén-Hägg1,
  2. Karolina Andersson2,
  3. Sofia Kälvemark-Sporrong1,3,
  4. Lena Ring1,
  5. Åsa Kettis-Lindblad1
  1. 1Department of Pharmacy, Uppsala University, Uppsala, Sweden
  2. 2Nordic School of Public Health, Göteborg, Sweden
  3. 3Department of Public Health & Caring Sciences, Uppsala University, Uppsala, Sweden
  1. Correspondence to Mrs Annika Nordén-Hägg, Department of Pharmacy, Uppsala University, Dag Hammarskjölds väg 238L, Uppsala S-756 52, Sweden; Annikanordn.h{at}


Background Since 2004, a web-based reporting system enables monitoring of dispensing errors in all Swedish pharmacies. The adoption of this system was followed by an overall increase in reports, mainly explained by the dispensing of medicines of improper strength. In 2006 an intervention was implemented, aimed at reducing these errors. The objective of this study was to assess the impact of the intervention on the number of errors.

Methods Monthly data on the reported number of dispensing errors from July 2004 until December 2007 were used. These were analysed in total and subdivided by type and cause of error. A time-series design was applied, and linear segmented regression analysis used to analyse whether changes in slope or level occurred; shifts in intercept or slope where p<0.01 were considered as statistically significant.

Results The intervention coincided with a distinct decrease in error reports and a statistically significant change in slope that switched from a slight increase, 0.09, to a decrease, −0.26 (p=0.0035). Medicines dispensed with wrong strength also displayed a significant change in slope, from 0.08 to −0.27 (p<0.0001), as well as dispensing errors caused by registration failure, that is, failure of the registration of a prescription in pharmacy computers, which changed from 0.05 to −0.29 (p<0.0001).

Conclusion The intervention was associated with a decrease in the number of reports on drugs dispensed with the wrong strength, but also had a decreasing effect on errors caused by registration failure and on the dispensing errors in total as well.

  • Incident reporting
  • adverse event
  • continuous quality improvement

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  • Competing interests AN-H and SK-S were formerly employed by the National Corporation of Swedish Pharmacies. AN-H was responsible for the development and the implementation of the intervention.

  • Provenance and peer review Not commissioned; externally peer reviewed.