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Research in the International Journal of Human Factors and Ergonomics has examined outpatient prescribing and found that overworked pharmacists as well as systemic workplace flaws can lead to dispensing errors. According to the World Health Organization (WHO), such errors remain a major and preventable cause of patient harm worldwide.

The researchers conducted their study in a large outpatient medical center. They combined situational analysis, in-depth interviews, and detailed surveys to build a human-centered picture of medication and prescribing safety. Instead of framing mistakes as individual failings, the study focused on the environmental, cognitive, and systemic pressures shaping how well pharmacists performed in their roles.

Pharmacists commonly reported greater workloads than other health care professionals, with high time pressure and prolonged periods of standing, bending, and repetitive motion being problems they raised. Indeed, half of pharmacists reported persistent musculoskeletal discomfort over the past year, most commonly in the neck, shoulders, and knees.

Notably, these symptoms did not vary significantly with years of experience nor specific job role. This, the researchers suggest, means that physical strain is an inherent feature of the current work environment for pharmacists rather than a temporary issue.

The study identified several key risk factors for dispensing errors: tiredness, frequent interruptions during work and pharmaceutical names and packaging that are very similar. These factors reflect both human vulnerabilities, such as cognitive overload, and systemic weaknesses such as inefficient workflow and poor packaging design.

The WHO has warned that medication-related harm is one of the top preventable causes of injury and death, and if counted as a disease, it would rank among the leading causes of mortality. Dispensing errors are thus part of a wider global challenge. Many such mistakes might be avoided by better working conditions for pharmacists and improved systems from the manufacturer's production and packaging plant to the pharmacy shelves.

More information: Kuo Wei Su et al, The multidimensional determinants of outpatient pharmacy dispensing errors: a mixed approach, International Journal of Human Factors and Ergonomics (2025). DOI: 10.1504/IJHFE.2025.10072708