International Journal of Clinical Pharmacy

https://doi.org/10.1007/s11096-020-01126-w

RESEARCH ARTICLE

Incidence, nature, severity, and causes of dispensing errors

in community pharmacies in Jordan
Derar H. Abdel‑Qader1 · Ahmad Z. Al Meslamani1 · Penny J. Lewis2 · Salim Hamadi1

Received: 16 March 2020 / Accepted: 10 August 2020

© Springer Nature Switzerland AG 2020

Abstract
Background Medication dispensing is a core function of community pharmacies, and errors that occur during the dispens-
ing process are a major concern for pharmacy profession. However, to date there has been no national study of medication
dispensing errors in Jordan. Objective The study aimed to investigate the incidence, nature, severity, causes and predictors
of medication dispensing errors. Setting The study was conducted in randomly selected community pharmacies across
Jordan. Method A mixed method approach was taken, incorporating prospective disguised observation of dispensing errors
and interviews with pharmacists regarding the causes of errors. A multidisciplinary committee evaluated the severity of
errors. Proportionate random sampling was used to include 350 pharmacies from across all regions of Jordan. SPSS (Ver-
sion 24) was used for data analysis. Main outcome measure Incidence, nature, severity, causes and predictors of medication
dispensing errors. Results The overall rate of medication dispensing errors was 24.6% (n = 37,009/150,442), of which 11.5%
(n = 17,352/150,442) were prescription related errors and 13.1% (n = 19,657/150,442) pharmacist counselling errors. The
most common type of prescription-related errors were wrong quantity (37.9%, n = 6584/17,352), whereas the most com-
mon pharmacist counselling error was wrong drug (41.9%, n = 8241/19,657). The majority of errors were caused by poor
handwriting (30.7%, n = 75,651/37,009), followed by high workload (17.3%, n = 22,964/37,009). More than half of errors
(52.6%) were moderate in severity, followed by minor errors (38.8%), and 8.6% of errors were rated as serious. Predictors
of medication dispensing errors were: Sundays (OR 2.7; 95% CI 2.15–3.94; p = 0.02), grade A pharmacies (dispensing ≥ 60
prescriptions a day (OR 3.6; 95% CI 2.89–4.78; p = 0.04)), and prescriptions containing ≥ 4 medication orders (OR 4.1; 95%
CI 2.9–6.4; p = 0.001). Conclusion Medication dispensing errors are common in Jordan and our findings can be generalised
and considered as a reference to launch training programmes on safe medication dispensing and independent prescribing
for pharmacists.

Keywords  Community pharmacy · Dispensing errors · Jordan · Medication errors · Medication safety · Pharmacist

Impacts on practice • Poor dispensing practice calls for a comprehensive plan

• Unless preventive measures are taken, dispensing errors
in community pharmacies may cause significant harm to
patients.
to support the continuing professional development of
pharmacy staff in safe dispensing.
Introduction

Medication dispensing is a fundamental function of commu-

nity pharmacies, and errors that occur during the dispensing
* Derar H. Abdel‑Qader process are a major concern for the pharmacy profession
derar.balawi@uop.edu.jo; d.balawi@igec.com.au [1]. In the literature, the incidence of medication dispens-
ing errors (MDEs) in community pharmacies in the UK and
1
Faculty of Pharmacy and Medical Sciences, University the USA ranges from 0.04 to 3.32% and from 0.08 to 24%,
of Petra, Amman, Jordan
respectively [1]. A systematic review estimated that MDEs
2
Division of Pharmacy and Optometry, The University rates in hospitals varied between countries (0.015–33.5%)
of Manchester, Manchester, UK

13
Vol.:(0123456789)

[2]. This wide variation in the incidence of MDEs can be
attributed to multiple factors including; study design and
method of error detection; the type of dispensing system
(manual or automated) as operational definitions, including
error definition and classification [1].
The most common types of MDEs reported in the UK
community setting were: wrong drug, strength, and formu-
lation [3–5]. In the USA, MDEs in the community setting
most commonly involved the supply of the wrong strength
of medication, incorrect formulation, and labelling errors
[6–9]. The majority of dispensing errors are identified before
the medication reaches the patient [1]. In Denmark, a low
rate (1/10,000) of MDEs was discovered, but many of these
errors were clinically serious [10]. The causes of dispensing
errors have been explored in various countries and factors,
such as work overload and pharmacists fatigue, have been
highlighted as contributory factors [11–13]. Furthermore,
community pharmacists in Jordan have reported poor physi-
cian handwriting as a major risk factor for MDEs [14].
As in most countries, community pharmacies in Jordan
are considered a trusted point of care for patients, who can
easily access pharmacists for medication supply and free
medical consultation [15]. Jordanian pharmacists have lim-
ited continual professional development opportunities and
there is a lack of government-supported legislations [16].
Therefore, a high rate and different types of MDEs may be
anticipated in Jordan.
Aim of the study
The study aimed to investigate the incidence, nature, sever-
ity, causes and predictors of MDEs.
Ethics approval
The study was approved by the institutional review board
(IRB) of the University of Petra (15H-11-2019).
Method
Study design and setting
This study was a prospective, observational study carried
out over 5 months (from October 2019 to February 2020) in
community pharmacies across all 12 regions of Jordan. To
avoid the Hawthorne effect, disguised direct observation of
the pharmacy dispensary team was conducted; only the com-
munity pharmacy manager was informed about the objec-
tives of our study, whereas the pharmacists and pharmacy
13
International Journal of Clinical Pharmacy
technicians were told that our researchers would investigate
the prescribing trends of physicians.
Sample size calculation and sampling technique
The total number of community pharmacies in Jordan is
2801; consequently, the estimated sample size was 338 phar-
macies, using Raosoft sample size calculator (95% confi-
dence interval, 5% margin of error, and 50% the response
distribution) [17]. Anticipating 3% contingency, we aimed to
include 350 community pharmacies in our study. Pharmacies
were divided in four geographical regions using proportion-
ate random sampling: Northern, Southern Region, Capital
Region and Central Region. Due to their cultural and socio-
economic differences. More than half (56%, 196/350) of the
targeted pharmacies were included from the Capital Region.
21% (74/350) from the Northern Region, 19% (66/350)
from the Central region, and 4% (14/350) from the South-
ern Region. To achieve the targeted sample, we approached
421 community pharmacies; 53 refused to participate and
18 pharmacies dropped out. Reasons for dropping out were:
not operating on a regular basis; not providinng easy access
to the research team to observe the dispensing process,
or having unsuitable conditions for conducting a research
(small size, light workload). The nearest pharmacy in the
area was approached to replace any pharmacy excluded from
the study.
Definition, operational definitions, and types
of errors
Our study adopted a definition for MDEs based on previous
studies [3, 5, 18], which is: ‘any unintended deviation from
an interpretable written prescription or medication order.
Both content and labeling errors are included. Any unin-
tended deviation from professional or regulatory references,
or guidelines affecting dispensing procedures, is also con-
sidered a dispensing error. Our study included only errors
detected up to and including the point at which the medica-
tion was handed over to the patient or the patient’s represent-
ative (‘near-misses’). The operational definitions of MDEs
were adopted from Cohen’s classification of MDEs [18] and
tailored to our setting (Table 1). To meet the aim of our
study, we expanded the scope of MDEs to include medica-
tions dispensed based on pharmacist’s counselling; this type
of error occurred when a prescription only medicine (POM),
a pharmacy medicine (P) or a general sale list (GSL) medi-
cine was prescribed independently by the pharmacist to the
patient without an order from a physician. Although illegal,
this is a common practice in Jordan, with the exception of
narcotic analgesics and hypnotic-anxiolytics. Hence, MDEs
were divided into pharmacist counselling errors (PCEs) and
prescription-related errors (PREs).
International Journal of Clinical Pharmacy

Table 1  Dispensing error classification

Type of dispensing error Definition

Wrong drug Occurs when a medication different from that named in writing on a prescription is used to fill the prescrip-
tion
Wrong strength Occurs when a dosage unit containing an amount of medication different from what the prescriber specified
is used to fill a prescription
Wrong dosage form Occurs when the form of the medication used to fill the prescription differs from what the prescriber wrote
Wrong quantity Occurs when the amount of medication dispensed to a patient differs from the amount ordered without
acceptable reason
Omission Occurs when the pharmacist doesn’t dispense all medications written in the prescription
Wrong preparation Occurs when the pharmacist fails to prepare the medication appropriately for the patient e.g. constituting
suspensions and preparing creams
Deteriorated drug Occurs when a medication is beyond its expiration date or is stored in location that is not in accordance with
the manufacturer’s recommendations
Wrong instruction for drug usage Occurs when the pharmacist is poorly knowledgeable about the method of administration of certain medica-
tions (e.g. inhalers or oral dispersible tablets) requested by the physician
Labelling errors These errors are divided into two types: Wrong label instruction errors (transcription error) which occur
when directions to the patient on the prescription label deviate in one or more ways from what was pre-
scribed (dosage, method of administration or incomplete information). The second type of label error is
wrong patient, in which the pharmacist fills a prescription unintentionally to another patient
Pharmacist counseling Occurs when the pharmacist independently counsels the patient and prescribes a medication without physi-
cian prescription. Sub-types of this error are: wrong drug, wrong dosage, contraindication, etc

Inclusion criteria increased from 5 to 7 days per pharmacy. Researchers were

• All medications (with and without prescriptions) up to
and including the point at which they were handed to the
patient or the patient’s representative.
• All erroneous medication dispensing incidents inter-
cepted by the researcher (near-misses).
Exclusion criteria
• A prescription with any type of prescribing error (inter-
cepted or unintentionally dispensed).
• Incidents detected after the patient had taken possession
of the medication and left the pharmacy.
Piloting
A pilot study was conducted in five community pharmacies
from different regions for three days. During piloting, the
research team tested: (1) the appropriateness and accuracy
of the data collection form; (2) time needed for the study; (3)
the cooperation of community pharmacists in-charge; and
(4) the optimal approach for observing errors without affect-
ing patient privacy. As community pharmacies in Jordan did
not operate an electronic system linking physician orders
directly to the pharmacy; thus, types of errors related to this
system, such as selection errors, were omitted from the data
collection form. After piloting, the period of the study was
instructed to have no interaction with patients. The piloting
study data were not included in the final data set.
Data collection
The research team developed a standardised data collection
form, which included information about the prescription,
such as: the number of medications, type of error, staff grade
and causes of errors. As Sunday is not a day off in Jordan.
Each research pharmacist collected data for seven days (all
days of the week, 9am–5pm) at a designated pharmacy. At
the end of each research day, the main investigator (DAQ)
and the research assistant (AZM) reviewed and confirmed
the detected errors against the eligibility criteria; those not
matching the criteria were removed. In order to investigate
the incidence and predictors of MDEs, the research team
recorded the total number of prescriptions and medications
dispensed during the study period at each pharmacy. At the
end of each observational week, the researcher conducted a
structured interview with the pharmacy staff who commit-
ted errors to investigate the causes of intercepted MDEs and
associated circumstances.
The research team was composed of 15 licensed phar-
macists. They were given training on patient safety and the
professional practice of dispensing medications by the prin-
cipal investigator (DAQ). This training comprised of two
lectures (3 h) on medication errors, particularly dispensing
errors (types, classification, and clinical significance), and
three workshops on detecting dispensing errors, accurate

13

completion of the data collection form and correct use of
operational definitions. Recruited community pharmacy
managers signed a consent form indicating their willing-
ness to participate. Research pharmacists were paid after
data collection was completed.
Severity of the MDEs
A multidisciplinary committee, comprising an internist,
a general practitioner and a clinical pharmacist, rated the
severity of the errors. We adopted a validated method for
rating and quantifying the responses of the committee [19].
Based on Raosoft’s sample size calculator [17], 384 inci-
dents from the collected MDEs were randomly selected for
evaluation of clinical severity. Committee members were
then asked to rate severity on a 10-pointscale from 0 (no
effect) to 10 (death) and the mean score across all judges
was used as an index of clinical severity. Categorisation of
potential severity was adopted from a previous study [3];
a score of less than 3 represented a minor error, a score
between 3 and 7 a moderate error, and a score of more than
7 a serious error. As for MDEs causes, the reported answers
were categorised with their cumulative percentages. The
Kappa statistic was used to test the interrater reliability of
the committee members. A Kappa value of below 0.5 was
considered bad reliability, between 0.5 and 0.7 moderate
reliability, between 0.7 and 0.8 good reliability, and above
0.8 great reliability [20].
Data analysis
Data were coded and entered into the Statistical Package for
Social Science (­ SPSS®) version 24 (IBM, Chicago, IL, US)
by the investigator. Descriptive results are presented as pro-
portions (%) with 95% CIs, while logistic regression results
are presented as odd ratios (ORs) with 95% CI. Statistical
significance was considered at p value < 0.05 (with a con-
fidence limit at 95%). Multivariate logistic regression was
conducted to investigate significant predictors for dispensing
errors (dependent variable). Independent variables, chosen
from the literature and available variables at the time of the
study were pharmacy location, pharmacy grade, pharmacy
type, experience of pharmacist, day of the week, and number
of medications on a prescription. Only significant variables
were discussed in the results.
Results
Of 350 community pharmacies included in our study, 55.1%
(n = 193/350) were located in urban areas and the majority
(60.9%, n = 213/350) dispensed 11–59 prescriptions a day. A
13
International Journal of Clinical Pharmacy
high proportion of items (33.4%, n = 50,203/150,442) were
dispensed on Sundays compared to other days (Table 2).
The total number of MDEs was 37,009 (24.6%; CI 95%,
22.9–26.1) intercepted in 150,442 dispensed medications;
this included 17,352 PREs (11.5%; CI 95%, 9.2–13.7), and
19,657 PCEs (13.1%; CI 95%, 10.1–14.9). Rates of errors
among regions ranged from 13.5 to 31.7%. The majority of
errors were made by pharmacists (79.6%, n = 29,441/37,009)
followed by pharmacy assistants (12.4%, n = 4603/37,009).
The most common types of PREs were wrong quan-
tity (37.9%, n = 6584/17,352) (Fig.  1), wrong strength
(26.6%, n = 4614/17,352) and wrong dosage form (13.0%,
n = 2264/17,352) errors. The least frequent type was instruc-
tion error (1.1%, n = 196/17,352). Results showed that the
most common types of PCEs were wrong drug (41.9%,
n = 8241/19,657), wrong strength (20.7%, n = 4063/19,657),
wrong dosage form (17.9%, n = 3511/19,657) and wrong
quantity (10.8%, n = 2127/19,657) errors; the least common
was label error (0.4%, n = 69/19,657).
Antibiotics (22.5%, n = 8315/37,005) and analgesics
(21.3%, n = 7875/37,009) accounted for most of the erro-
neous medications (Table  3). There was no significant
difference for erroneous medications between PREs and
PCEs except for common cold medications (3.9% vs. 14%;
p < 0.05, respectively) and antihypertensives (10.0% vs.
1.8%; p < 0.05, respectively).
The major causes of MDEs were poor handwriting
(30.7%, n = 75,651/37,009) and heavy workload (17.3%,
n = 22,964/37,009). Sub-categorisation of causes showed
that poor handwriting was the most common cause of
PREs, whereas inexperienced staff was a listed reason for
the majority of PCEs (Fig. 2).
The majority of MDEs were moderate (52.6%,
n = 202/384) and minor (38.8%, n = 149/384); 8.6%
(n = 33/384) were serious errors (Table 4). Inter-rater reli-
ability was strong and significant (K = 0.71; p < 0.05). Pre-
dictors of MDEs were: Sundays (OR 2.7; 95% CI 2.15–3.94;
p = 0.02), grade A pharmacies dispensing ≥ 60 prescriptions
a day (OR 3.6; 95% CI 2.89–4.78; p = 0.04) and prescrip-
tions containing ≥ 4 medication orders (OR 4.1; 95% CI
2.9–6.4; p = 0.001).
Discussion
The overall rate of MDEs was 24.6% (n = 37,009/150,442),
which included 11.5% (n = 17,352/150,442) PREs and
13.1% (n = 19,657/150,442) PCEs. Although a formal statis-
tical comparison is not possible, our results showed a higher
dispensing error rate compared to other studies conducted in
community pharmacies in the UK 3% [3], USA 1.7% [9], and
Denmark 1/10,000 [10]. Our results also showed a higher
error rate than studies conducted in hospitals in Thailand
International Journal of Clinical Pharmacy

Table 2  Categorisation and characteristics of pharmacies, prescriptions and dispensed items

Items Capital region (No, %) Central region (No, %) North region (No, %) South region (No, %) Total (No, %)

Pharmacy characteristics
 Location
  Rural (78, 39.8%) (31, 47%) (38, 51.4%) (10, 71.4%) (157, 44.9%)
  Urban (118, 60.2%) (35, 53%) (36, 48.6%) (4, 28.6%) (193, 55.1%)
 Grade
  A* (41, 20.9%) (9, 13.6%) (12, 16.2%) (1, 7.1%) (63, 18%)
  B* (116, 59.2%) (43, 65.2%) (48, 64.9%) (6, 42.9%) (213, 60.9%)
  C* (39, 19.9%) (14, 21.2%) (14, 18.9%) (7, 50%) (74, 21.1%)
 Staff experience
  < 5 Years (109, 55.6%) (43, 65.2%) (35, 47.3%) (9, 64.3%) (196, 56%)
  > 5 Years (87, 44.4%) (23, 34.8%) (39, 52.7%) (5, 35.7%) (154, 44%)
 Type
  Chain (123, 62.8%) (37, 56.1%) (67, 9.5%) (2, 14.3%) (229, 65.4%)
  Independent (73, 37.2%) (29, 43.9%) (67, 90.5%) (12, 85.7%) (121, 34.6%)
Dispensing characteristics
 Number of medication orders
per prescription
  1 – – – – (18,389, 24.6%)
  2 – – – – (23,498, 31.4%)
  3 – – – – (18,709, 25.0%)
  ≥ 4 – – – – (14,239, 19.0%)
 Dispensed items during days
of the week
  Saturday – – – – (13,651, 9.1%)
  Sunday – – – – (50,203, 33.4%)
  Monday – – – – (17,541, 11.6%)
  Tuesday – – – – (15,654, 10.4%)
  Wednesday – – – – (17,565, 11.7%)
  Thursday – – – – (26,364, 17.5%)
  Friday – – – – (9464, 6.3%)

*A; dispenses ≥ 60 prescriptions a day, B; dispenses 11–59 prescriptions a day, C; dispenses ≤ 10 prescriptions a day

Fig. 1  Types of dispensing Prescripon related errors Pharmacist’s counseling errors

errors (n = 37,009)
2127 69
169 182
4063 798
3511 497
8241
6584 471
351 341
4614 780
2264 196
1751

13
 International Journal of Clinical Pharmacy

Table 3  Therapeutic Medication category Prescription related Pharmacist’s coun- p value of Total

categorisation of erroneous errors (n, %) seling errors (n, %) difference
medications (n = 37,009)
Analgesic (3261, 18.8%) (4614, 23.5%) > 0.05 (7875, 21.3%)
Antibiotic (4514, 26.0%) (3801, 19.3%) > 0.05 (8315, 22.5%)
Common cold medicine (1032, 6.0%) (3362, 17.2%) < 0.05 (3412, 9.2%)
Antispasmodic (541, 3.1%) (471, 2.4%) > 0.05 (1012, 2.7%)
Anticoagulant (175, 1.0%) – – (175, 0.5%)
Antifungal (714, 4.1%) (1321, 6.7%) > 0.05 (2035, 5.5%)
Antihypertensive drug (1741, 10.0%) (354, 1.8%) < 0.05 (2095, 5.7%)
Anti-obesity medication (178, 1.0%) (314, 1.6%) > 0.05 (492, 1.3%)
Antiviral drug (214, 1.2%) (677, 3.4%) > 0.05 (891, 2.4%)
Anti-inflammatory (687, 4.0%) (1132, 5.8%) > 0.05 (1819, 4.9%)
Steroid (321, 1.8%) (413, 2.1%) > 0.05 (734, 2.0%)
Dietary supplements (451, 2.6%) (1221, 6.2%) > 0.05 (1672, 4.5%)
Anti-diabetic medication (861, 5.0%) – – (861, 2.3%)
Antidiarrhoeal (923, 5.3%) (1260, 6.4%) > 0.05 (2183, 5.9%)
Antidepressant (236, 1.4%) – – (236, 0.6%)
Hormone (341, 2.0%) – – (341, 0.9%)
Anticonvulsant (268, 1.5%) – – (268, 0.7%)
Othersa (894, 5.2%) (717, 3.7%) > 0.05 (1611, 4.4%)
a
 Any therapeutic category has less than 0.5% percentage; p < 0.05 is considered signficant 

Fig. 2  Causes of dispensing Poor Handwring

errors (n = 37,009)

Ambiguous direcons

Similar drug name

Similar packaging
2.5%
4.0%
Medicine replaced with near 6.0%
4.5%
expired one
30.7%
Off-label use without
9.9%
counseling
Heavy workload
17.3%
Low staffing 9.2%
7.1%
4.7%
Interrupons
1.7% 2.4%
Complex prescripon

Day of the week

Inexperienced staff

1.67% [21] and France 2.5% [22]. However, our findings approaches, operational definitions and geographic locations
showed a lower error rate than a study conducted in a general might have contributed to the variation in rates between
hospital in Brazil 81.8% [23]. The different methodological studies; hence, the difficulty in making direct comparisons.

13
International Journal of Clinical Pharmacy

Table 4  Examples of medication dispensing errors

Examples of errors as presented to the commit- Error type Error cause Clinical severity
tee

Naproxen 500 mg prescribed to be taken two Wrong strength High workload Minor
times daily; the pharmacist dispensed Nap-
roxen 250 mg and label stated ‘take one tablet
twice a day’
Dexamethasone elixir prescribed for a 5-year Label errors dosage Poor hand writing Minor
child to be taken 5 ml three times daily for
3 days. The label stated ‘take 5 ml three times
daily for a week’
Pharmacist dispensed insulin aspart expired Deteriorated drug Interruption Moderate
1 month ago
Pharmacist wrongly taught patient how to use Wrong instruction for drug usage Inexperienced staff Moderate
budesonide and formoterol inhaler
Pharmacist dispensed Norethisterone acetate Wrong drug Similar packaging Moderate
instead of Chlordiazepoxide
Pharmacist prescribed fusidic acid cream for Pharmacist counseling Inexperienced staff Serious
ringworm
Folic acid 400mcg prescribed for a pregnant Wrong strength Inexperienced staff Serious
woman to be taken once a day; pharmacist
dispensed folic acid 5 mg
Betamethasone cream prescribed for a patient Label errors dosage Interruption Serious
suffering from eczema to be applied once a
day for a week; the label stated ‘apply on a dry
skin two times daily for one month’
Miconazole nitrate cream prescribed to be Wrong dosage form High workload Day of the week Serious
applied topically for a 12-year girl suffer-
ing from itchy vagina; pharmacist dispensed
miconazole suppository
Pharmacist prescribed gabapentin instead of Wrong drug Poor handwriting look-alike, sound-alike Serious
celecoxib
Pharmacy assistant prescribed diclofenac Pharmacist counseling Inexperienced staff Serious
sodium 12.5 mg suppository to a feverish
3-month old baby
Pharmacist dispensed Vitamin D 50,000 Units Wrong strength Poor handwriting Serious
capsule; doctor wrote ‘Vitamin D 5000U cap
(U read as 0)

Our holistic operational definitions of MDEs, encompassing
both PREs and PCEs, and our disguised direct observation
approach, may well have contributed to the high MDE rate
in our study. Moreover, health authorities in Jordan focus on
controlling the dispensing of narcotic and hypnotic medica-
tions, with much less oversight of over-the-counter and pre-
scription medications; this may indirectly increase the rate
of MDEs. In contrast, studies that used self-reported inci-
dent forms, surveys, or case note review for reporting errors
cannot demonstrate a reliable incidence of errors, because
these approaches are vulnerable to a broad range of biased
behaviours leading to under detection of medication errors.
In addition, the dispensing process in community pharma-
cies in Jordan is not supported by electronic systems, which
may decrease some types of errors. We believe all these fac-
tors could influence the detected rate of errors considerably.
Our interpretations are consistent with the findings of other
studies conducted in community settings [10, 24, 25] and in
hospitals [7, 26–28].
A high rate of PCEs was detected in our study. Such
errors were most commonly attributed to poor knowledge
or inexperienced pharmacy staff. In the Middle East, phar-
macists tend to provide pharmaceutical care, raising their
profits by independently prescribing medications to patients.
Unfortunately, though, pharmacists do not receive proper
clinical training after graduation for their continuous pro-
fessional development or to become licensed independent
prescribers.
In our study, a high rate of wrong quantity errors was
detected in PREs (37.9%). Poor handwriting and work
overload might have contributed to pharmacists ignoring
the quantity of the medication prescribed. Wrong drug
errors were the most commonly encountered type (41.9%)
of PCEs, which is consistent with other studies [4, 5]. This

13

finding highlights the fact that pharmacists in Jordan require
continuous education in pharmacotherapy, especially for
outpatients.
Our results showed that around half of MDEs were
caused by poor handwriting and heavy workload. The fact
that the prescribing process in Jordan is still hand-written
and the brand name of medication is written on the prescrip-
tion rather than the scientific name may well cause such a
high rate of MDEs. These results were partially consistent
with those of a UK study [5].
A significantly higher proportion of common cold medi-
cations were involved in PCEs compared to PREs, whilst a
significantly greater proportion of antihypertensives were
involved in PREs compared to PCEs. In Jordan, most anti-
hypertensives have similar packages; this might have caused
confusion among pharmacists, particularly among inexpe-
rienced staff.
The majority of MDEs were rated as moderate and minor;
only 8.6% of errors were serious. In a similar study con-
ducted in the UK, most of the errors were assessed as minor
67% and moderate 32% [3]. In addition, nearly 45% of hospi-
tal MDEs were reported in a study as significant and serious
[22]. Despite the similarity between our results and the lit-
erature, our approach may be more reliable as we included a
significant number of incidents for the committee compared
to the total number of errors.
The number of medication orders on a prescription (≥ 4
medications) and busy pharmacies significantly predicted
the occurrence of MDEs. The impact of these factors on the
emergence of dispensing errors can be reduced by increas-
ing staff numbers along with continuous pharmaceutical
care training on the procedure of dispensing a prescription.
Sundays were found to be 2.7 times more likely to incur
MDEs than other days. In Jordan, Sunday is a particularly
busy day in the community as it the first working day of
the week. Predictors of MDEs in community pharmacies
have not been assessed in many studies [3, 5]. A study
showed that opportunities for errors in hospital pharmacies
were higher in the pre-typed prescription order forms (odds
ratio = 4.5; p < 0.001), in those with 9 or more drugs (odds
ratio = 4.0; p < 0.001), and with those for injectable drugs
(odds ratio = 5.0; p < 0.001) [23].
There is a paucity of research on MDEs in community
pharmacies. This was the first study in the Middle East to
investigate the rate, types, causes, predictors and clinical
severity of MDEs. Our results could be generalised due the
study’s robust sampling strategy that included randomly
selected pharmacies from across all regions of Jordan. We
adopted holistic and valid operational definitions of MDEs
and used disguised direct observation of errors enhancing
the validity of the findings. The study also added a new,
previously unexplored perspective to the literature, investi-
gating all MDEs types including those based on pharmacist’s
13
International Journal of Clinical Pharmacy
counselling and independent prescribing (PCEs), a com-
mon yet little researched practice in community pharmacies
across Jordan and the Middle East. The main limitation of
our research is the variation between research pharmacists in
their ability to detect errors. Furthermore, the cross-sectional
nature of our method provides descriptive evidence of dis-
pensing incidents and causes without prompting additional
insight to the solutions. Nevertheless, our data are reliable
and our technique can be widely applied as a long-term
method for detecting and reporting of MDEs. Further stud-
ies investigating the impact of outpatient electronic prescrib-
ing systems linked to community pharmacies on the rate of
errors are recommended.
Conclusion
MDEs occur frequently (24.6% of all dispensed medications)
in community pharmacies in Jordan and most reported errors
are moderate. There is a need to improve the education of
community pharmacists and their teams to ensure safe dis-
pensing practice and to investigate potential interventions,
such as electronic systems, to decrease the number of errors
and reduce the risk of patient harm.
Acknowledgements  We thank the University of Petra for facilitating
our research. Our thanks go Dr. Abdullah Albassam, Dr. Nadia Al
Mazrouei, and Dr. Osama Mohamed Ibrahim for their support.
Funding  Derar H Abdel Qader received grant support from the Uni-
versity of Petra (88/2019 on 29/01/2019).
Conflicts of interest  The authors declare that they have no conflict of
interest.
References
1. James KL, Barlow D, McArtney R, Hiom S, Roberts D, Whit-
tlesea C. Incidence, type and causes of dispensing errors: a review
of the literature. Int J Pharm Pract. 2009;17(1):9–30.
2. Aldhwaihi K, Schifano F, Pezzolesi C, Umaru N. A systematic
review of the nature of dispensing errors in hospital pharmacies.
Integr Pharm Res Pract. 2016;5:1–10.
3. Franklin BD, O’Grady K. Dispensing errors in community
pharmacy: frequency, clinical significance and potential impact
of authentication at the point of dispensing. Int J Pharm Pract.
2007;15(4):273–81.
4. Chua S, Wong ICK, Edmondson H, Allen C, Chow J, Peacham
J, et al. A feasibility study for recording of dispensing errors and
‘near misses’ in four UK primary care pharmacies. Drug Saf.
2003;26(11):803–13.
5. Ashcroft DM, Quinlan P, Blenkinsopp A. Prospective study of the
incidence, nature and causes of dispensing errors in community
pharmacies. Pharmacoepidemiol Drug Saf. 2005;14(5):327–32.
6. Allan EL, Barker KN, Malloy MJ, Heller WM. Dispens-
ing errors and counseling in community practice. Am Pharm.
1995;NS35(12):25–33.
International Journal of Clinical Pharmacy
7. Flynn EA, Barker KN. Effect of an automated dispens-
ing system on errors in two pharmacies. J Am Pharm Assoc.
2006;46(5):613–5.
8. Varadarajan R, Barker KN, Flynn EA, Thomas RE. Comparison
of two error-detection methods in a mail service pharmacy serving
health facilities. J Am Pharm Assoc (2003). 2008;48(3):371–8.
9. Flynn EA, Barker KN, Carnahan BJ. National observational study
of prescription dispensing accuracy and safety in 50 pharmacies.
J Am Pharm Assoc. 2003;43(2):191–200.
10. Knudsen P, Herborg H, Mortensen AR, Knudsen M, Hellebek
A. Preventing medication errors in community pharmacy: fre-
quency and seriousness of medication errors. Qual Saf Health
Care. 2007;16(4):291–6.
11. Peterson GM, Wu MS, Bergin JK. Pharmacist’s attitudes towards
dispensing errors: their causes and prevention. J Clin Pharm Ther.
1999;24(1):57–71.
12. Szeinbach S, Seoane-Vazquez E, Parekh A, Herderick M. Dis-
pensing errors in community pharmacy: perceived influence of
sociotechnical factors. Int J Qual Health Care. 2007;19(4):203–9.
13. Flynn EA, Barker KN, Berger BA, Lloyd KB, Brackett PD. Dis-
pensing errors and counseling quality in 100 pharmacies. J Am
Pharm Assoc. 2009;49(2):171–82. https:​ //doi.org/10.1331/JAPhA​
.2009.08130​.
14. Gogazeh E. Dispensing errors and self-medication practice
observed by community pharmacists in Jordan. Saudi Pharm J.
2020;28(3):233–7.
15. Wazaify M, Shields E, Hughes CM, McElnay JC. Societal per-
spectives on over-the-counter (OTC) medicines. Fam Pract.
2005;22(2):170–6.
16. Elayeh E, Akour A, Madain S, AlQhewii T, Basheti I. Practice of
pharmaceutical care In community pharmacies in Jordan. Trop J
Pharm Res. 2016;16(2):463–70.
17. Raosoft L. Raosoft sample size calculator. 2004 [cited 2020 Jun
1]. http://www.raoso​ft.com/sampl​esize​.html.
18. Hansen LB. Medication Errors, vol. 71. New York: American
Journal of Pharmaceutical Education; 2007.
19. Dean BSBN. A validated, reliable method of scoring the severity
of medication errors. Am J Heal Pharm. 1999;56(1):57–62.
20. McHugh ML. Interrater reliability: the kappa statistic. Biochem
Med. 2012;22(3):276–82.
21. Kristina SA, Supapsophon P, Sooksriwong C. Dispensing errors :
preventable medication errors by pharmacists in outpatient depart-
ment, A University Hospital, Bangkok, Thailand. Hs-09-of.:5–9.
22. Bohand X, Simon L, Perrier E, Mullot H, Lefeuvre L, Plotton C.
Frequency, types, and potential clinical significance of medica-
tion-dispensing errors. Clinics. 2009;64(1):11–6.
23. Anacleto TA, Perini E, Rosa MB, César CC. Drug-dispensing
errors in the hospital pharmacy. Clinics. 2007;62(3):243–50.
24. Franklin BD, Reynolds M, Sadler S, Hibberd R, Avery AJ, Arm-
strong SJ, et al. The effect of the electronic transmission of pre-
scriptions on dispensing errors and prescription enhancements
made in English community pharmacies: a naturalistic stepped
wedge study. BMJ Qual Saf. 2014;23(8):629–38.
25. Nordén-Hägg A, Andersson K, Kälvemark-Sporrong S, Ring L,
Kettis-Lindblad Å. Reducing dispensing errors in Swedish phar-
macies: the impact of a barrier in the computer system. Qual Saf
Heal Care. 2010;19(6):e22.
26. Moniz TT, Seger AC, Keohane CA, Seger DL, Bates DW, Roth-
schild JM. Addition of electronic prescription transmission to
computerized prescriber order entry: effect on dispensing errors
in community pharmacies. Am J Heal Pharm. 2011;68(2):158–63.
27. Cooke P, Southall C, Kauldhar K, Waters P. Evaluation of an
automated dispensing system in a hospital pharmacy dispensary.
Pharm J. 2005;274(3):354–61.
28. Franklin BD, O’Grady K, Voncina L, Popoola J, Jacklin A. An
evaluation of two automated dispensing machines in UK hospital
pharmacy. Int J Pharm Pract. 2008;16(1):47–53.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
13