The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.

Bryony Dean Franklin; Matthew Reynolds; Stacey Sadler; Ralph Hibberd; Anthony Avery; Sarah Armstrong; Rajnikant Mehta; Matthew J. Boyd; Nick Barber

Study

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.

May 14, 2014

Franklin BD, Reynolds M, Sadler S, et al. BMJ Qual Saf. 2014;23(8):629-38.

View more articles from the same authors.

This study of medication dispensing errors at community pharmacies found that electronic transmission of prescriptions resulted in increased omission of the medication indication, but that other error types did not change. These findings suggest that electronic prescribing alone is not sufficient to address outpatient dispensing errors.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Methodological variations and their effects on reported medication administration error rates.

February 27, 2013

Failure mode and effects analysis outputs: are they valid?

August 15, 2012

Failure mode and effects analysis: too little for too much?

April 18, 2012

Is failure mode and effect analysis reliable?

May 27, 2009

Medication errors with electronic prescribing (eP): two views of the same picture.

July 21, 2010

Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study.

November 13, 2019

The incidence and nature of prescribing and medication administration errors in paediatric inpatients.

February 24, 2010

The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study.

August 22, 2007

Exploring safety systems for dispensing in community pharmacies: focusing on how staff relate to organizational components.

September 17, 2014

A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis.

March 7, 2012

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.

December 16, 2020

Improving feedback on junior doctors' prescribing errors: mixed-methods evaluation of a quality improvement project.

April 27, 2016

Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions.

September 2, 2009

The frequency and nature of prescribing problems by general practitioners in training (REVISiT).

June 15, 2022

Systematic review of medication errors in pediatric patients.

October 25, 2006

Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation in an English hospital.

July 11, 2018

How reliable are clinical systems in the UK NHS? A study of seven NHS organisations.

April 25, 2012

A prospective risk assessment of informal carers' medication administration errors within the domiciliary setting.

August 2, 2017

Understanding the facilitators and barriers to barcode medication administration by nursing staff using behavioural science frameworks. A mixed methods study.

November 1, 2023

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study.

July 29, 2020

Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems.

July 31, 2019

The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety.

July 22, 2020

Analysis of pharmacist-identified medication-related problems at two United Kingdom hospitals: a prospective observational study.

March 18, 2020

Developing strategic recommendations for implementing smart pumps in advanced healthcare systems to improve intravenous medication safety.

November 16, 2022

Patient involvement in medication safety in hospital: an exploratory study.

July 16, 2014

Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids.

April 9, 2014

What constitutes a prescribing error in paediatrics?

October 19, 2005

Exploring the theory, barriers and enablers for patient and public involvement across health, social care and patient safety: a systematic review of reviews.

February 10, 2021

Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis.

April 5, 2023

Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase.

February 23, 2011

Carers' medication administration errors in the domiciliary setting: a systematic review.

February 8, 2017

The secondary use of data to support medication safety in the hospital setting: a systematic review and narrative synthesis.

February 23, 2022

Use of pediatric injectable medicines guidelines and associated medication administration errors: a human reliability analysis.

February 23, 2022

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

January 11, 2023

Identifying risks areas related to medication administrations - text mining analysis using free-text descriptions of incident reports.

February 12, 2020

Exploring the sociotechnical intersection of patient safety and electronic health record implementation.

October 16, 2013

Primary care medication safety surveillance with integrated primary and secondary care electronic health records: a cross-sectional study.

July 22, 2015

Exploring the role of guidelines in contributing to medication errors: a descriptive analysis of national patient safety incident data.

February 21, 2024

Appropriateness of use of medicines in elderly inpatients: qualitative study.

August 31, 2005

Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis.

December 18, 2019

Is health care getting safer?

November 26, 2008

Examining variations in prescribing safety in UK general practice: cross sectional study using the Clinical Practice Research Datalink.

November 25, 2015

Paediatric dosing errors before and after electronic prescribing.

August 18, 2010

Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety.

July 10, 2019

Bayesian cohort and cross-sectional analyses of the PINCER trial: a pharmacist-led intervention to reduce medication errors in primary care.

June 27, 2012

How can patient-held lists of medication enhance patient safety? A mixed-methods study with a focus on user experience.

February 5, 2020

To what extent is the World Health Organization's Medication Safety Challenge being addressed in English hospital organizations? A descriptive study.

February 16, 2022

Challenges and potential solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports across 94 hospitals

September 1, 2021

Measuring safety in older adult care homes: a scoping review of the international literature.

May 19, 2021

Evaluation and certification of computerized physician order entry systems.

November 22, 2006

Quality of medication use in primary care—mapping the problem, working to a solution: a systematic review of the literature.

October 21, 2009

The evidence base for US Joint Commission hospital accreditation standards: cross sectional study.

July 13, 2022

Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD).

September 15, 2021

The potential of Twitter as a data source for patient safety.

January 27, 2016

A scoping review of non-professional medication practices and medication safety outcomes during public health emergencies.

January 25, 2023

Improving general practice computer systems for patient safety: qualitative study of key stakeholders.

February 28, 2007

Capturing patients' perspectives on medication safety: the development of a patient-centered medication safety framework.

May 8, 2019

Lack of emergency medical services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care.

March 24, 2010

The contribution of staffing to medication administration errors: a text mining analysis of incident report data.

December 18, 2019

Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976–2015.

May 17, 2017

Professional, structural and organisational interventions in primary care for reducing medication errors.

October 18, 2017

Structural empowerment, Magnet hospital characteristics, and patient safety culture: making the link.

April 5, 2006

State medical board regulation of compounding in physician offices.

June 9, 2021

Comparison of quality measures from US hospitals with physician vs nonphysician chief executive officers.

November 2, 2022

Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality indicators: a multicenter study of freestanding children's hospitals.

June 11, 2008

The influence of formulation and medicine delivery system on medication administration errors in care homes for older people.

January 30, 2011

Electronic prescribing reduced prescribing errors in a pediatric renal outpatient clinic.

February 13, 2008

Resource-based view on safety culture's influence on hospital performance: the moderating role of electronic health record implementation.

September 19, 2018

Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial.

November 14, 2012

Measuring patient safety in primary care: the development and validation of the "Patient Reported Experiences and Outcomes of Safety in Primary Care" (PREOS-PC).

June 1, 2016

Building a Patient Safety Toolkit for use in general practice.

July 20, 2016

Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate.

December 21, 2016

A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy.

January 14, 2015

Characteristics of medical liability claims against dermatologists from 1991 through 2015.

December 20, 2017

The WHO World Alliance for Patient Safety: a new challenge or an old one neglected?

May 11, 2005

November 22, 2006

Errors and discrepancies in the administration of intravenous infusions: a mixed methods multihospital observational study.

June 6, 2018

Identification of priorities for improvement of medication safety in primary care: a PRIORITIZE study.

December 14, 2016

What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior?

July 15, 2009

Assessment of attitudes toward deprescribing in older Medicare beneficiaries in the United States.

December 19, 2018

Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research.

May 9, 2018

Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes.

April 27, 2005

Adverse events related to accidental unintentional ingestions from cough and cold medications in children.

August 26, 2020

Medication errors from over-the-counter cough and cold medications in children.

May 6, 2020

Development of a checklist of safe discharge practices for hospital patients.

April 24, 2013

Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports.

June 7, 2017

Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome.

June 3, 2015

Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries.

May 24, 2023

Diagnostic overshadowing in dentistry.

September 11, 2019

Electronic prescribing systems in hospitals to improve medication safety: a multi-methods research programme.

December 21, 2022

Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.

January 9, 2019

A systematic review of simulation for multidisciplinary team training in operating rooms.

February 13, 2013

Developing a learning health system: insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care.

November 14, 2018

Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation.

February 23, 2011

Shifting the learning curve.

January 19, 2011

Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital discharge and primary care follow-up.

October 29, 2014

The outcomes of recent patient safety education interventions for trainee physicians and medical students: a systematic review.

July 15, 2015

Multidisciplinary obstetric simulated emergency scenarios (MOSES): promoting patient safety in obstetrics with teamwork-focused interprofessional simulations.

July 8, 2009

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

October 21, 2009

Patient safety features of clinical computer systems: questionnaire survey of GP views.

June 29, 2005

Related Resources

Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II.

August 9, 2023

Using sociotechnical theory to understand medication safety work in primary care and prescribers' use of clinical decision support: a qualitative study.

May 24, 2023

ISMP Targeted Medication Safety Best Practices for Community Pharmacy.

April 19, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

WebM&M Cases

Duplicate Therapies in Retail Pharmacy

March 15, 2023

Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety.

February 22, 2023

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

February 1, 2023

Concerns regarding tablet splitting: a systematic review.

December 7, 2022

Journal Article

Study

Patient Safety Innovations

Predicting dispensing errors in community pharmacies: an application of the Systematic Human Error Reduction and Prediction Approach (SHERPA).

November 16, 2022

The impact of electronic communication of medication discontinuation (CancelRx) on medication safety: a pilot study.

October 5, 2022

The electronic prescribing of subcutaneous infusions: a before-and-after study assessing the impact upon patient safety and service efficiency.

June 15, 2022

Exploration of prescribing error reporting across primary care: a qualitative study.

April 13, 2022

Mapping the resilience performance of community pharmacy to maintain patient safety during the Covid-19 pandemic.

February 16, 2022

Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors.

October 26, 2021 - October 26, 2021

Electronic health record interoperability-why electronically discontinued medications are still dispensed.

September 22, 2021

Perceptions of working conditions and safety concerns in community pharmacy.

September 8, 2021

CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.

September 1, 2021

WebM&M Cases

Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.

July 28, 2021

The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study.

July 28, 2021

Pharmacist and prescriber responsibilities for avoiding prescription drug misuse.

July 28, 2021

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study.

May 5, 2021

Work effort, readability and quality of pharmacy transcription of patient directions from electronic prescriptions: a retrospective observational cohort analysis.

March 31, 2021

Prescribers' perspectives on including reason for use information on prescriptions and medication labels: a qualitative thematic analysis.

March 10, 2021

'It's all about patient safety': an ethnographic study of how pharmacy staff construct medicines safety in the context of polypharmacy.

March 10, 2021

A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system.

December 23, 2020

Dispensing Errors.

December 16, 2020

Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims.

November 4, 2020

Organisational factors associated with safety climate, patient satisfaction and self-reported medicines adherence in community pharmacies.

June 17, 2020

WebM&M Cases

A Mistaken Dose of Naloxone 

December 18, 2019

WebM&M Cases

The Lost Start Date: an Unknown Risk of E-prescribing

October 30, 2019

See More About The Topic

Outpatient Pharmacy

Pharmacists

Quality and Safety Professionals

Information Professionals

Community Pharmacy

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.

Predicting dispensing errors in community pharmacies: an application of the Systematic Human Error Reduction and Prediction Approach (SHERPA).

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.

Predicting dispensing errors in community pharmacies: an application of the Systematic Human Error Reduction and Prediction Approach (SHERPA).

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site