Phar vol 21_1 05-02-1999 11:44 Pagina 25
PHAR 149 pips 166051
Hospital drug distribution systems in the UK and Germany -
a study of medication errors
• K a t j a Ta x i s , B r y o n y D e a n a n d N i c k B a r b e r
Pharm World Sci 1999;21(1): 25-31.
© 1999 Kluwer Academic Publishers. Printed in the Netherlands.
Katja Taxis (correspondence), Bryony Dean and Nick
Barber: Centre for Pharmacy Practice, The School of
Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK.
Email: ktaxis@cua.ulsop.ac.uk
Keywords
Drug distribution system
Medication errors
Traditional drug distribution system
Unit dose system
Ward pharmacy system
Abstract
The aim of this study was to compare the incidence of
medication errors and the stages of the drug distribution
system at which they occur in a United Kingdom (UK)
hospital using the ward pharmacy system, a German hospital
using the unit dose system and a German hospital using their
traditional system. Medication errors were identified by
observing the preparation and administration of regularly
scheduled solid oral medication.
In the UK hospital using the ward pharmacy system, the
medication error rate was 8.0% (95% confidence interval
6.2-9.8%). The majority of these errors occurred at the stage
of medication administration. In the hospital using the
traditional German system, the error rate was 5.1%
(4.4-5.8%). With the German unit dose system, the error
rate was 2.4% (2.0-2.8%). In both German systems the
errors were mainly attributable to the stage of transcription.
It was noted that patient turnover was much higher in the
wards using the ward pharmacy system and therefore the
study sites may not be comparable. However,
recommendations can be made in order to reduce the error
rate associated with each system. Errors associated with the
ward pharmacy system may be reduced if medication is
stored in individual patient medicine cabinets and patients’
own drugs used. Errors occurring with the traditional system
and the unit dose system may be reduced if the original
prescription is used for medication administration.
Accepted March 1998
Introduction
In any hospital, a drug distribution system is required
to supply the medication prescribed for each inpa-
tient. The drug distribution system includes all the
processes that occur between the prescription of a
drug and the administration of that drug to the
patient. There are many varieties of drug distribution
system in use throughout the world, but all have the
same goal: to ensure that each dose of medication
administered to each patient is exactly that which was
intended by the prescriber. A measure of the quality
of any drug distribution system is the incidence of
medication errors, where a medication error is any
discrepancy between the medication prescribed and
that administered.
The first studies of medication errors were carried
out in the United States of America (USA) [1] and the
United Kingdom (UK) [2 3] in the 1960s. Very high
rates of errors were identified, prompting the devel-
opment of different drug distribution systems in each
country. UK hospitals adopted the ward pharmacy
system [4] and in the USA, the unit dose system was
introduced [5]. Subsequent research demonstrated
Articles
that error rates had decreased in each country [6 7].
Since that time, research into medication errors has
continued to develop, and observation of medication
preparation and administration has become accepted
as the most reliable method of identifying medication
errors [8].
Little medication error research has been carried
out elsewhere in Europe. A small number of studies
have been published, but the standard observation-
based method was not used and the results are there-
fore difficult to interpret [9-12]. For example, the first
German medication error study included errors in the
recording of verbal orders, other documentation
errors and administration errors, and the results do
not distinguish between them [13]. This study had lit-
tle impact as the error rate of 4.6% was not consid-
ered high and only minor changes to the traditional
drug distribution system were suggested. Other stud-
ies have since been carried out in German hospitals,
[14-16] but none have used the standard observa-
tion-based method.
Recently, some hospitals in Germany have begun
to implement unit dose systems [17 18]. Reasons for
the move to unit dose drug distribution include short-
ages of nursing staff and desire to reduce risk, reduce
costs and increase pharmacists’ involvement with
drug therapy [19]. However, although the unit dose
system was shown to decrease medication errors in
the USA in the 1960s, it cannot be assumed that this
will also apply to other health care cultures in the
1990s. It is not known how the medication error rates
of the traditional and unit dose systems in Germany
compare with each other or with other drug distribu-
tion systems such as the ward pharmacy system.
We therefore decided to measure the medication
error rate in a UK hospital using the ward pharmacy
system, a German hospital using the traditional
system and a German hospital using the unit dose
system. In previous studies, medication errors have
generally been classified according to type (wrong
drug, wrong dose, etc.) [8]. However, this taxonomy
is not helpful in identifying the causes of errors or
how they can be prevented. We therefore decided to
determine the stages of each system in which medi-
cation errors originated, in order to identify the most
vulnerable stages and suggest strategies to reduce
errors. Previous medication error studies have been
criticised for failing to consider the importance of the
errors identified [20]; we therefore included a meas-
ure of clinical severity.
Pharmacy World & Science
Methods
Definitions
Volume 21 Nr. 1 1999
Definitions were based on those of Allan and Barker
[8]. A medication error was defined as a dose of medi-
cation administered to a patient that deviated from
the doctor’s prescription. Wrong time errors and pre- 25
Phar vol 21_1 05-02-1999 11:44 Pagina 26
scribing errors were not included, however prescrip-
tions that were illegible or ambiguous were included
as a source of error.
The denominator used to calculate the medication
error rate was the total number of opportunities for
error (OE). An opportunity for error was defined as any
dose administered or any dose prescribed but omit-
ted. Doses were only included as OE if the researcher
had observed their preparation and could determine
whether or not a medication error had occurred.
Doses of medication placed at patients’ bedsides
were included as OE even if their consumption by the
patient was not observed.
Study sites
The study was carried out between May and July
1997 at an 850 bed UK hospital using the ward phar-
macy system, a 600 bed German hospital using the
traditional drug distribution system and an 880 bed
German hospital using the unit dose system.
At the UK hospital, doctors prescribed medication
directly onto patients’ drug charts [21]. About 80% of
the drugs needed on each ward were kept as ward
stock; the remainder were dispensed for individual
patients. Each ward was visited by a designated phar-
macist twice daily from Monday to Friday and once
on Saturdays, who initiated the supply of any non-
stock drugs required. Each day, the pharmacist also
checked that all prescriptions were legal, unambigu-
ous and clinically appropriate. The pharmacy was
open Monday to Friday 8:30 am until 5:30 pm and
on Saturday and Sunday mornings. A resident phar-
macist was available at all other times. Nurses admin-
istered medication using a drug trolley which was
wheeled from bed to bed during each of the four
daily drug administration rounds. The drug chart,
kept at the end of each bed, was used to determine
the drugs to be administered and to record their
administration.
In the hospital using the traditional German
system, each ward kept a large floor stock of formu-
lary drugs which were ordered from the pharmacy
department twice a week by nursing staff. The phar-
macy was open Monday to Friday 7:30 am until 4
pm; an on-call pharmacist was available at all other
times. Pharmacists visited each ward twice a year.
Doctors prescribed medication in a section of the
patient’s medical notes that was also used to give
other instructions to the nurses. The doctor set a
coloured marker on the patient’s notes to indicate to
the nursing staff the presence of a new prescription.
Nursing staff then transcribed the prescriptions onto
drug administration charts in the patient’s notes.
Prescriptions for regularly administered oral medica-
tion were transcribed at the same time onto a drug
administration card for each patient. Each patient’s
drug administration card was placed under the plastic
cover of their section of a drug administration tray,
Pharmacy World & Science
and was used by nurses to prepare medication in the
drug preparation room for each of the four daily drug
rounds. The administration of medication was not
recorded.
The second German hospital studied had started to
Volume 21 Nr. 1 1999
implement a unit dose system three years previously.
Wards using the unit dose system were visited by a
pharmacist twice a day. The pharmacy was open 7
am until 7 pm on weekdays and 8 am until 3 pm on
26
Saturdays. At other times, an on-call pharmacist was
available. On admission, medication was prescribed
on patients’ admission sheets. Subsequent changes
were written on sheets filed in the patient’s notes, as
in the traditional system. Either a nurse or a pharma-
cist could enter prescriptions into the computer
system although all entries had to be verified by a
pharmacist before they could be dispensed. Patient
medication profiles were printed after each change
and filed in patients’ notes. Medication was dis-
pensed every 24 hours in the pharmacy department
using a Baxter ATC 212 automated tablet counter.
Unit dose packages were automatically labelled with
patient name and room number, drug details and
time of administration, before being placed by tech-
nicians into individual patient drawers in a drug trol-
ley. A pharmacist then checked the dispensed medi-
cation before its delivery to the ward. A range of
drugs was kept as ward stock and could be used to
administer urgent medication. Four drug rounds
were carried out each day; administration of medica-
tion was not documented.
Data collection
Information on patient numbers was obtained at each
site, so that the characteristics of the wards studied
could be compared.
Medication errors were identified using an observa-
tion-based method [1] on two adult wards at each
site. On each ward, a researcher (BD or KT in the UK;
KT in both German hospitals) attended every drug
administration round scheduled for the weekdays of
one week and observed the preparation and adminis-
tration of regularly scheduled solid oral doses of med-
ication. It was anticipated that this data collection
schedule would allow the observation of 1000 OE at
each site, a sample size calculated to be sufficient to
conclude that a difference in error rates of 3% was
statistically significant (a = 0.05; b = 0.2) within the
range of error rates expected [22]. The researcher
recorded details of each dose that was administered
and compared these with the original prescription to
identify any discrepancies. This comparison took
place concurrently in the UK hospital where the origi-
nal prescription was used for medication administra-
tion, and retrospectively in both German hospitals
where original prescriptions were not used for admin-
istration. Since errors were identified concurrently in
the UK hospital, for ethical reasons the researcher
intervened to prevent the occurrence of any error
that was considered harmful; such incidents were
included as medication errors. However if the nurse or
patient prevented an error from occurring this was
not counted as a medication error. Nursing staff at
each site were informed that the aim of the study was
to identify the advantages and disadvantages of dif-
ferent drug distribution systems. Approval for the
study was obtained from hospital management at
each site.
In the hospital using the traditional German
system, the administration of medication to individual
patients could not be observed because three or more
nurses administered medication at once. However the
preparation of each dose was observed; it was
assumed that no changes to the medication occurred
after the nurses left the drug preparation room.
Phar vol 21_1 05-02-1999 11:44 Pagina 27

Data analysis possible to include the night time drug rounds as

The percentage incidence of medication errors was
calculated for each site, and for each researcher at the
UK hospital. Ninety-five percent confidence intervals
were calculated for error rates and their differences
[23]. If the 95% confidence interval (CI) for the differ-
ence between two error rates does not include zero
then the difference is statistically significant. The
medication errors identified were classified according
to mutually exclusive categories of type (Appendix 1)
and the stage of the system in which they occurred
(Appendix 2). The number of failures in each drug
distribution system was also calculated. One failure
included all medication errors that had the same ori-
gin and occurred to the same patient. For example,
the incorrect transcription of a prescription can be
considered to be one failure in the drug distribution
system, regardless of how many medication errors
result. The potential significance of each system fail-
ure was assessed using a severity scale developed at
the London School of Pharmacy [24]. This is an objec-
tive scale which takes into account the legal classifica-
tion and the therapeutic index of the drug con-
cerned, the number of errors resulting from each fail-
ure in the system, whether the error resulted in the
drug being used outside its product license and the
likelihood of any serious adverse effect. Each of these
factors is scored, and then added to produce an over-
all score. Scores range from 0 to 100; a score of less
than 50 is considered to be of minor severity. Two
pharmacists each carried out the scoring indepen-
dently.
nurses prepared medication while carrying out other
duties. However, only about 8% of the daily medica-
tion was administered during this round. In the hospi-
tal using the unit dose system 36 out of 40 scheduled
drug rounds were observed. The observer missed the
first drug rounds on each ward due to a delay in intro-
ducing the study to ward staff.
The error rates for the three systems were found to
be significantly different to each other.
The 95% CI for the difference between the error
rates of the ward pharmacy system and the traditional
system was 0.6% to 5.2%. The 95% CI for the differ-
ence between the ward pharmacy system and the
unit dose system was 3.6% to 7.6%. The 95% CI for
the difference between the two German hospitals was
1.1% to 4.3%. Figures 1 and 2 show the errors ana-
lysed according to type and the stage of the system in
which they originated.
Table 3 shows the numbers of OE and errors identi-
fied by each observer in the UK hospital. The differ-
ence in the error rates identified by each researcher is
not significant (95% CI for the difference -0.7% to
6.7%).
The medication errors identified resulted from 50
failures in the drug distribution system in the UK hos-
pital, 23 in the German hospital using the traditional
system and 20 in the German hospital using the unit
dose system. The severity scores for these are shown
in Figure 3; the two researchers agreed on the scores
in 100% of cases.

Results
Characteristics of the wards studied are shown in
Table 1. Error rates identified at each site are summar-
ised in Table 2. In the UK hospital, all scheduled drug
rounds were observed during the study period, how-
ever on one ward two nurses sometimes administered
medication at the same time using two drug trolleys;
in such cases medication preparation and administra-
tion for only half of the patients could be observed. In
the hospital using the traditional system 30 out of 40
scheduled drug rounds were observed; it was not
Discussion
Rates and types of errors
Significantly different medication error rates were
identified in the three hospitals studied. The unit dose
system was associated with the lowest error rate and
the ward pharmacy system with the highest. As well
as having different overall error rates, the three
systems were associated with different types of error
that occurred in different stages of the drug distribu-
tion system.
The predominant type of error associated with the

Table 1 Comparison of wards during the study period

Ward pharmacy system Traditional system Unit dose system

Ward General General General Rehabilitation Respiratory Urology

medical medical surgical

Beds 28 20 32 30 30 37
Mean LOSa 5.3 2.5 6.8 39.3 10.6 9.3
Mean bed occupancy 90% 94% 53% 88% 86% 96%
Admissions 16 21 4 3 13 10
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Discharges 16 21 8 2 7 8
Nursing staff
morning 6 5 3-4 6 3-4 4-5
afternoon 4-5 5 3 6 3 3
evening 3 4 1 1 1 1
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Solid oral doses 389 454 256 717 778 540

Doses/patient day 6.2 4.8 3 5.4 4.9 3.75
a LOS = length of stay in days.
27
Phar vol 21_1 05-02-1999 11:44 Pagina 28
ward pharmacy system was omission. At the ordering
stage these were mainly due to unavailability of non-
stock drugs; at the administration stage these were
mainly due to nurses missing doses on the drug chart
and not being able to locate medication in the drug
trolley. In particular, nurses had problems finding
stock drugs that were prescribed by generic name but
were supplied in manufacturer’s original packs with
brand names, such as doxazosin (supplied as
Cardura®) and enalapril (supplied as Innovace®).
Other errors also occurred at the administration stage
where nurses selected the incorrect preparation.
Such errors suggest training needs amongst nursing
staff. For example, on several occasions thiamine tab-
lets were selected instead of vitamin B compound
strong, and plain carbamazepine tablets were select-
ed where modified release tablets were prescribed.
On other occasions, modified release carbamazepine
tablets were crushed prior to administration, again
suggesting training needs.
In the German hospital using the traditional
system, the main types of errors were omission errors,
wrong dose errors and extra dose errors. About half of
the omissions were due to unavailability of non-for-
mulary medication. Other omission errors and extra
dose errors were due to incorrect or delayed tran-
scription. For example, in one case a patient was pre-
scribed co-beneldopa but did not receive any during
the study period as the prescription was not tran-
scribed onto the patient’s drug administration card.
In other cases doses were apparently not noticed on
the drug administration cards. The majority of the
wrong dose errors that occurred with the traditional
system were due to the transcription of prescriptions
for 15 millilitres of paracetamol suspension (750 mg)
as a 500 mg tablet.
The most common type of error that occurred in
the unit dose system was omission. These mainly orig-
inated in the transcription stage, where transcription
was either delayed or did not occur. Errors in the tran-
scription stage also resulted in some wrong drug and
wrong dose errors. The remaining omission errors
occurred in the administration stage, where doses
were sometimes left in patients’ drawers in the drug
trolley.
Table 2 Opportunities for error and medication errors observed at each site
Opportunities for error
Ward pharmacy system 842
Traditional system 973
Unit dose system 1318
aCI = confidence interval.
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Table 3 Opportunities for error and medication errors identified by each observer in the hospital using
the ward pharmacy system
Researcher Opportunities for error
Volume 21 Nr. 1 1999
BD 411
KT 431
a CI = confidence interval.
28
The severity scores were similar for the system fail-
ures that occurred at each site, and suggest that the
majority were relatively minor in nature.
The error rate in the UK hospital was surprisingly
high. Error rates of between 2.8% and 5.7% [21 25-
29] have previously been reported for UK hospitals
using the ward pharmacy system. Furthermore, one
of the previous studies cited [21] was carried out at
the same hospital as the present study using identical
methods and identical medication error definitions;
the two general medical wards studied had an overall
medication error rate of 2.0%. In the four year period
between the two studies, patient turnover has
increased considerably and this is one factor that may
have contributed to the increase in error rates. Ho et
al. [28] found that medication error rates were higher
in the first 48 hours after prescribing and the first 48
hours after patient admission. Wards with a higher
patient turnover will have a higher proportion of
patients in these higher risk categories.
Limitations to the study
We were not able to include intravenous, ‘as
required’, liquid, inhaled or controlled drugs in the
study. This was because these drugs were adminis-
tered separately to the main drug rounds in one or
more of the hospitals studied. The error rate associat-
ed with these types of medication is therefore not
known. We also excluded weekends. Ho et al. [28]
found that the error rate on a care of the elderly ward
was significantly lower during weekends than week-
days. However it is not known whether this finding is
generalisable to other wards and other drug distribu-
tion systems. Future studies should therefore include
weekends.
The method used in this study has an inherent limi-
tation: the effect of the observer on the observed
nurse. Although any such effect would be difficult to
measure, the same method was used in each of the
three hospitals and any effect should be equal in
each. Alternative methods of identifying medication
errors have been shown to be unreliable [1 30] and
observation therefore remains the method of choice.
There were wide variations between wards in mean
length of stay, percentage bed occupancy and num-
Medication errors Error rate (95% CIa)
67 8.0% (6.2% - 9.8%)
50 5.1% (4.4% - 5.8 %)
32 2.4% (2.0% - 2.8%)
Medication errors Error rate (95% CIa)
39 9.5% (6.7% - 12.3%)
28 6.5% (4.2% - 8.8%)
Phar vol 21_1 05-02-1999 11:45 Pagina 29

Figure 1
Medication errors analysed according to type.

Figure 2
Medication errors analysed according to the stage of the system in which they occurred.

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Volume 21 Nr. 1 1999

Figure 3
Severity scores for the failures in each drug distribution system. 29
Phar vol 21_1 05-02-1999 11:45 Pagina 30
bers of admissions and discharges. Each of these
parameters could affect the incidence of medication
errors, therefore limiting the comparisons that can be
made. Although wards should be selected so as to be
comparable, in practice this is very difficult to
achieve. Differences in ward and hospital characteris-
tics may also limit the generalisability of our findings
to other wards and other hospitals. For example,
nurses’ knowledge of medication, their training and
experience might influence medication error rates.
Further research should be carried out in this area.
Differences between the three drug distribution
systems necessitated minor changes in the methods
used at each site. For example, the observer inter-
vened to prevent errors occurring on five occasions in
the UK hospital but did not do so during the study in
either German hospital. In the hospital using the tra-
ditional system it was not possible to observe the
night time drug rounds and we had to assume that
no changes occurred in the prepared medication after
nurses left the drug preparation room. The effect of
such differences on observed error rates is not known
but is not considered to be significant.
This study focused only on medication errors and
did not consider other advantages and disadvantages
of the three systems. For example, we did not consider
how much money and staff time each system required.
Strengths and weaknesses of each system
In the ward pharmacy system, the doctor’s original
prescription is used for the preparation and adminis-
tration of drugs. This prevents the occurrence of any
transcription errors and represents the major strength
of this system. In both of the German systems, tran-
scription was identified as a vulnerable stage. In all
three systems, errors were attributed to the adminis-
tration stage. The system with the lowest error rate
associated with this stage was the unit dose system,
where the task of selecting the right preparation is
transferred to the automated dispensing machine in
the pharmacy department. The highest error rate
associated with the administration stage was found in
the ward pharmacy system, where nurses had to pre-
pare medication in a busy patient care area and were
frequently interrupted. A further weakness of the
ward pharmacy system is that doses of newly pre-
scribed non-stock medication are often omitted.
Unavailability of medication was also a problem in the
hospital using the traditional system.
Recommendations
Errors associated with the ward pharmacy system
might be reduced if all individually dispensed medica-
tion is stored in individual bedside cabinets [31].
Such a system should aid the location of each
patient’s medication, and if patients’ own medication
is used, decrease the number of doses omitted due to
unavailability. Education of nursing staff may also be
Pharmacy World & Science
required, including how and when medication should
be obtained outside pharmacy opening hours and
highlighting the differences between different phar-
maceutical formulations.
The use of the original prescription for medication
Volume 21 Nr. 1 1999
preparation and administration may reduce the error
rate in the hospital using the traditional system.
Review of prescriptions by pharmacists and recording
of administration by nursing staff may reduce other
30
errors.
Errors associated with the unit dose system would
also be reduced if the original prescription could be
used for administration. The introduction of compu-
terised prescribing may address this issue and should
be evaluated.
Conclusion
In this study, there was a lower medication error rate
associated with the German unit dose system than
with the traditional German system and the UK ward
pharmacy system. Although the wards studied may
not have been comparable, the study has highlighted
some of the strengths and weaknesses associated
with each system and has demonstrated that none of
the systems were error-free. Different drug distribu-
tion systems are vulnerable at different stages, and
efforts to reduce errors should be focused according-
ly. More work is needed to compare the risks, costs
and benefits of different hospital drug distribution
systems.
Acknowledgements
This research was carried out in part fulfilment of
Katja Taxis’ MSc in Clinical Pharmacy, which was
funded by the German Academic Exchange Service.
Bryony Dean is the recipient of a research training fel-
lowship from the UK NHS Executive (South Thames).
The authors would also like to thank Mr Gerhard
Carstens for his help in organising the German part of
the study, and the pharmacy and nursing staff at all
three study sites.
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improve the accuracy of drug administration? Pharm J
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1997;259:782-4.
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Appendix 1: Types of medication error

Omission
A prescribed dose that was not given by the time the next dose
was due. Doses withheld for clinical reasons or refused by the
patient were not included as errors.

Wrong dose
The administration of an amount of drug greater or less than
that prescribed. The halving of tablets was not considered to be
an error provided that this corresponded to the dose prescribed.

Wrong drug
The administration of a drug which was not that prescribed.

Extra dose
The administration of an additional dose of a prescribed medica-
tion. This included the administration of a dose after the drug
had been discontinued and the administration of a drug more
often than scheduled.

Unauthorised drug
The administration of a drug which was not prescribed for that
patient.

Wrong dosage form

Pharmacy World & Science

The administration of a drug in a different dosage form to that

prescribed. This included the administration of plain tablets
instead of enteric coated tablets and the crushing of modified
release preparations, but did not include the use of plain tablets
where a liquid was prescribed.

Expired drug
Volume 21 Nr. 1 1999

The administration of a drug that had deteriorated due to incor-

rect ward storage or had exceeded its expiry date.

31