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

Abstract

Objective: This study aimed to identify pharmacist professional liability patterns and trends associated with 2 of the most common allegations in legal claims: wrong drug dispensing errors and wrong dose dispensing errors.

Methods: This study used pharmacist professional liability claim data from the Healthcare Providers Service Organization professional liability insurance program, underwritten by CNA. The final 2018 claims dataset consisted of pharmacist professional liability (i.e., malpractice) claims that closed between 2012 and 2016 and incurred a payment of at least $1 from the Healthcare Providers Service Organization program. Using malpractice claim data, the claims were classified by clinical license (pharmacist or pharmacy technician), primary allegation type, and total payment amount. These claims were then analyzed to determine the risk factors that most often led to wrong drug and wrong dose dispensing errors and the factors that led to claims with higher-than-average total payments. Then, the results were compared with the 2013 claims dataset to identify patterns and trends.

Results: Inclusion criteria, applied to 1264 reported adverse incidents and claims, created the 2018 claim dataset consisting of 184 closed claims over the 5 years available for review. The average total payment was $124,407 for closed claims with a payment of at least $1. Wrong drug dispensing errors represented 36.8% of claims in the 2018 dataset, and wrong dose dispensing errors represented 15.3% of claims. Comparisons with the 2013 dataset revealed that the percentage of claims associated with wrong drug dispensing errors decreased from 43.8% in the 2013 dataset to 36.8% in the 2018 dataset. The percentage of wrong dose claims also decreased since the 2013 dataset from 31.5% to 15.3%.

Conclusion: Although technology and automation have contributed to improvements in the area of medication error prevention, wrong drug and wrong dose dispensing errors continue to occur because of system and human factor errors.