• Zizi Campmans, Arianne van Rhijn, René M Dull, Jacqueline Santen-Reestman, Katja Taxis, and Sander D Borgsteede.
• Department of Clinical Decision Support, Health Base Foundation, Houten, the Netherlands.
• Plos One. 2018 Jan 1; 13 (5): e0197469.

IntroductionDrug confusion is thought to be the most common type of dispensing error. Several strategies can be implemented to reduce the risk of medication errors. One of these are alerts in the pharmacy information system.ObjectiveTo evaluate the experiences of pharmacists and pharmacy technicians with alerts for drug name and strength confusion.MethodsIn May 2017, a cross-sectional survey of pharmacists and pharmacy technicians was performed in community pharmacies in the Netherlands using an online questionnaire.ResultsOf the 269 respondents, 86% (n = 230) had noticed the alert for drug name confusion, and 26% (n = 67) for drug strength confusion. Of those 230, 9% (n = 20) had experienced that the alert had prevented dispensing the wrong drug. For drug strength confusion, this proportion was 12% (n = 8). Respondents preferred to have an alert for drug name and strength confusion in the pharmacy information system. 'Alert fatigue' was an important issue, so alerts should only be introduced for frequent confusions or confusions with serious consequences.ConclusionPharmacists and pharmacy technicians were positive about having alerts for drug confusions in their pharmacy information system and experienced that alerts contributed to the prevention of dispensing errors. To prevent alert fatigue, it was considered important not to include all possible confusions as a new alert: the potential contribution to the prevention of drug confusion should be weighed against the risk of alert fatigue.

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