{
  "abstract": "Introduction: The types and causes of dispensing errors vary across the stages of the complex dispensing process in community pharmacies. Notably, the analysis of near-miss reports may facilitate improvements in healthcare environments and operational practices.\n\nAim: We aimed to identify the characteristics of the factors contributing to near-miss errors at each stage of the dispensing process and to determine which factors require priority action.\n\nMethod: We conducted a secondary analysis of near-miss dispensing errors voluntarily reported by community pharmacies through the near-miss reporting system of the Japan Council for Quality Health Care. The associations between various types of near-miss errors and their contributing factors were estimated using multivariate logistic regression models.\n\nResults: Among the 45,483 near-miss incidents, most were reported during the dispensing and accuracy-checking stages (n = 35,384, 77.8%). At the prescription data entry stage, near-miss errors were primarily associated with the usability of computer systems and look-alike/sound-alike (LASA) drug names. At the dispensing and accuracy-checking stage, the characteristic contributing factors included LASA drug names and similar appearances, patient preferences for brand name/generic, user-friendliness of equipment, and human factors among pharmacists. During the medicine supply stage, factors associated with inadequate confirmation of the patient’s understanding were identified. Finally, at the post-supply stage, patient-related factors and insufficient communication were identified as key contributors.\n\nConclusion: Based on the reported near-miss events, priority actions are required to address LASA drug names and similar appearances, generic prescription systems, labour-intensive dispensing practices, the usability of computer systems and equipment, and inadequate communication with patients.\n\nSupplementary Information: The online version contains supplementary material available at https://doi.org/10.1007/s11096-026-02208-x.",
  "abstract_shown": true,
  "affiliations": [
    "Graduate School of Pharmaceutical Sciences, Tokyo University of Science, 6-3-1 Niijuku, Katsushika-Ku, Tokyo, 125-8585 Japan",
    "Akebono Pharmacy, Akebono Pharmacy Group, 3302-3 Mitsukaido Suwa-machi, Joso-shi, Ibaraki 303-0021 Japan",
    "Department of Pharmacy, Faculty of Pharmaceutical Sciences, Tokyo University of Science, 6-3-1 Niijuku, Katsushika-Ku, Tokyo, 125-8585 Japan",
    "Research Division of Medical Data Science, Research Institute for Science and Technology, Tokyo University of Science, 2641 Yamazaki, Noda-Shi, Chiba 278-8510 Japan"
  ],
  "article_type": "research article",
  "arxiv": null,
  "author_total": 11,
  "authors": [
    {
      "affs": [
        0,
        1
      ],
      "name": "Takashi Umino"
    },
    {
      "affs": [
        0,
        2,
        3
      ],
      "name": "Tsugumichi Sato"
    },
    {
      "affs": [
        2
      ],
      "name": "Yoshiaki Shikamura"
    },
    {
      "affs": [
        2
      ],
      "name": "Kazushige Ijuin"
    },
    {
      "affs": [
        2
      ],
      "name": "Asuka Fujisawa"
    },
    {
      "affs": [
        2
      ],
      "name": "Yuki Iwama"
    },
    {
      "affs": [
        2
      ],
      "name": "Mayu Usami"
    },
    {
      "affs": [
        2
      ],
      "name": "Tomoe Asai"
    },
    {
      "affs": [
        2
      ],
      "name": "Mai Shimoyama"
    },
    {
      "affs": [
        2
      ],
      "name": "Rumoi Takahashi"
    },
    {
      "affs": [
        0,
        2
      ],
      "name": "Takehisa Hanawa"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/fdavg9wcfzf96.bib",
  "cited_by": 0,
  "doi": "10.1007/s11096-026-02208-x",
  "fulltext_url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC13731516/",
  "id": "fdavg9wcfzf96",
  "issns": [
    "2210-7703",
    "2210-7711"
  ],
  "landing_url": "https://doi.org/10.1007/s11096-026-02208-x",
  "language": "en",
  "licence": "CC-BY-NC-ND-4.0",
  "licence_label": "CC BY-NC-ND 4.0",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by-nc-nd/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "heading",
      "Research"
    ],
    [
      "openalex",
      "2739|Patient Safety and Medication Errors"
    ]
  ],
  "openalex": "W7208836228",
  "pdf_url": "https://link.springer.com/content/pdf/10.1007/s11096-026-02208-x.pdf",
  "pmcid": "PMC13731516",
  "pmid": "42700207",
  "published": "2026-09-05",
  "publisher": null,
  "ris": "https://research.draconitic.com/paper/fdavg9wcfzf96.ris",
  "sources": [
    {
      "first_seen": "2026-11-08T12:21:42Z",
      "native_id": "PMC13731516",
      "source": "pmc",
      "url": "https://doi.org/10.1007/s11096-026-02208-x"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "openalex:2739|Patient Safety and Medication Errors",
      "subfield": "epidemiology-public-health"
    }
  ],
  "title": "Near-miss dispensing errors in Japanese community pharmacies: error types and associated factors across dispensing stages",
  "title_text": "Near-miss dispensing errors in Japanese community pharmacies: error types and associated factors across dispensing stages",
  "type": "peer-reviewed",
  "updated_at": "2026-11-08T12:21:42Z",
  "url": "https://research.draconitic.com/paper/fdavg9wcfzf96",
  "venue": "International Journal of Clinical Pharmacy",
  "versions": []
}