Objective: The aim was to evaluate the potential causes of dispensing-label errors at a hospital.
Methods: The study took place at a 1200-bed NHS Foundation Trust with two main pharmacy dispensaries (one manual and one automated). Face-to-face interviews were conducted with staff involved in label-generation errors to obtain in-depth understanding of dispensing-label errors. Interviews were tape-recorded, transcribed and analysed with the aid of Nvivo into themes.
Key findings: Factors suggested as causing label-generation errors were illegible handwriting, lack of knowledge, hurrying through tasks, distractions, interruptions and the use of past medical records in generating labels. Self-checking every stage of the labelling process was suggested as the key to detecting and preventing errors.
Conclusions: The study highlights the vulnerability of the label-generation process to errors, with potential causes linked to organisational, environmental, task, team and individual factors.