Design for patient safety: a guide to the design of the dispensing environment

This booklet shows how the design of the dispensing environment can make the dispensing process safer in community pharmacies, dispensing doctor practices and hospital pharmacies.

Twenty-six (0.1%) dispensing incidents occur for every 22,000 items dispensed in community pharmacies. Of these incidents, 22 were classified as near misses, where the error was
discovered before the medicine was supplied to the patient. The remaining four (0.02%) were
classified as dispensing errors, when the incorrect medicine was supplied to the patient.

By breaking the dispensing process down into its constituent parts, each stage can be looked at individually and improved design applied to each one to make the process as safe as possible. This booklet looks at each stage in more detail.

Among the suggestions in the guide are:

• how changes to the general dispensing environment can improve patient safety; and 
• how design changes to the stages of dispensing a prescription can help reduce errors.

New factors that will impact on the dispensing process include electronic prescription services; auto-id and automation technologies; more responsibilities for pharmacy technicians; and enhanced pharmacy services. We have tried to take account of these in the guide.