Author(s)
Batoul Senhaji-Tomza, PharmD, MPH1
Audrey Kostrzewa, PharmD, MPH, BCPS2
Caroline Gaither PhD
BS Pharm FAPhA3
Lindsey Weis PharmD, MPH4
Nancy Lewis PharmD, MPH
C
ace Haugtvedt PhD, MS, BS Pharm5
Larry Selkow RPh, BS Pharm, FCPhA6
Affiliation(s)
1Touro College of Pharmacy, New York, 2Concordia University, Wisconsin, 3University of Minnesota, 4 Outocomes MTM ,Cardinal Health Company West, Des Moines, IA, 5St. Mary of the Woods College, Columbus, Ohio, 6Immediate Past President Southern California Public Health Association
Abstract:
Community pharmacies in the United States dispense more than 4.5 billion prescriptions annually, yet dispensing errors remain an underrecognized public health risk. Although often perceived as uncommon, these errors can cause significant patient harm, increase healthcare costs, and erode public trust. Key gaps include limited systematic surveillance, lack of standardized error and near-miss reporting, insufficient understanding of contributing factors (e.g., staffing, workflow pressures, technology, safety culture), and inconsistent accountability among regulators, payers, employers, and consumers.
The 2024 American Public Health Association policy highlights underreporting, limited data on error frequency and causes, and variability in state reporting requirements, underscoring the need for a standardized national framework. This proposal presents a practical, multicomponent strategy to reduce dispensing errors, strengthen safety culture, and improve patient outcomes in community pharmacy settings.
Methods / Proposed Strateg
y:: The policy advances a three-pronged approac
h::
1. Systematic Research & Data Collectio
n:: Implement standardized mechanisms to track, report, and analyze dispensing errors, including root cause analyses of staffing, workflow, technology, and training factors, and assess clinical and financial impact.
2. Safety Culture & Quality Improvemen
t:: Advance continuous quality improvement initiatives, interprofessional collaboration, and just culture principles to proactively prevent errors.
3. External Accountabilit
y:: Engage payers, regulators, patients, and the public to promote transparency, align incentives, and strengthen oversight.
Expected Outcomes / Significanc
e:: Implementation will generate reliable national data on error prevalence and causes; inform evidence-based staffing and workflow policies; strengthen safety culture; reduce preventable medication-related harm and associated costs; and enhance transparency and public trust. Even modest error reductions could prevent thousands of adverse events annually.
Conclusio
n:: A coordinated, evidence-based national strategy is essential to institutionalize dispensing safety and accountability in U.S. community pharmacy practice.