Near-miss dispensing errors in Japanese community pharmacies: error types and associated factors across dispensing stages
4 affiliations
- 1Graduate School of Pharmaceutical Sciences, Tokyo University of Science, 6-3-1 Niijuku, Katsushika-Ku, Tokyo, 125-8585 Japan
- 2Akebono Pharmacy, Akebono Pharmacy Group, 3302-3 Mitsukaido Suwa-machi, Joso-shi, Ibaraki 303-0021 Japan
- 3Department of Pharmacy, Faculty of Pharmaceutical Sciences, Tokyo University of Science, 6-3-1 Niijuku, Katsushika-Ku, Tokyo, 125-8585 Japan
- 4Research Division of Medical Data Science, Research Institute for Science and Technology, Tokyo University of Science, 2641 Yamazaki, Noda-Shi, Chiba 278-8510 Japan
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.
Aim: 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.
Method: 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.
Results: 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.
Conclusion: 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.
Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1007/s11096-026-02208-x.
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BibTeX
@article{umino2026nearmiss,
title = {{Near-miss dispensing errors in Japanese community pharmacies: error types and associated factors across dispensing stages}},
author = {Takashi Umino and Tsugumichi Sato and Yoshiaki Shikamura and Kazushige Ijuin and Asuka Fujisawa and Yuki Iwama and Mayu Usami and Tomoe Asai and Mai Shimoyama and Rumoi Takahashi and Takehisa Hanawa},
journal = {International Journal of Clinical Pharmacy},
year = {2026},
month = sep,
doi = {10.1007/s11096-026-02208-x},
url = {https://doi.org/10.1007/s11096-026-02208-x},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Near-miss dispensing errors in Japanese community pharmacies: error types and associated factors across dispensing stages
AU - Takashi Umino
AU - Tsugumichi Sato
AU - Yoshiaki Shikamura
AU - Kazushige Ijuin
AU - Asuka Fujisawa
AU - Yuki Iwama
AU - Mayu Usami
AU - Tomoe Asai
AU - Mai Shimoyama
AU - Rumoi Takahashi
AU - Takehisa Hanawa
PY - 2026
DA - 2026/09/05
JO - International Journal of Clinical Pharmacy
DO - 10.1007/s11096-026-02208-x
UR - https://doi.org/10.1007/s11096-026-02208-x
AB - 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. Aim: 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. Method: 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. Results: 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. Conclusion: 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. Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1007/s11096-026-02208-x.
SN - 2210-7703
SN - 2210-7711
ER -