National Observational Study of Prescription Dispensing Accuracy and Safety in 50 Pharmacies

Medication dispensing errors at a public pediatric hospital

“…Despite the adequate rate of pharmacists per number of beds (30:1), it was verified that the pharmacist's actions are focused on the administrative aspect of the dispensing process, and not on its care. There is strong evidence that the distribution system of unit doses can reduce the error rate and increase safety in the medication use process (4)(5)(6)(7)(8) .…”

“…The pharmacists and pharmacy technicians filled out the informed consent term, allowing the observation of dispensing activities, and were informed about the study aims to evaluate the dispensing system. They were not aware of the objectives and method used; these aspects were kept blind to the pharmacy team to avoid known biases (6)(7) . All errors that occurred during the study were codified and kept confidential.…”

“…They represent a severe social and health problem with important economic repercussions (3) and are classified as medication prescription, dispensing and administration errors. Dispensing errors occur during the medication dispensing process (4)(5)(6) .…”

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(4)(5)(6) .Literature suggests that the incidence of medication errors in pediatrics is twice or three times as high as in adults, and also that pediatric patients are at higher risk of death when compared to adults (7)(8)(9)(10)(11) . These errors also represent an important The pharmacy service is responsible for the safe and efficient use of medication in hospitals and plays an essential role in integrating the prescription, dispensing and administration processes and should have policies and procedures to prevent errors (4)(5)8) .

The rate of errors is considered one of the best indicators of quality of medication distribution systems and is still used to evaluate the safety of these systems (4,6,9) .

Some studies, published in the United States and England, showed an incidence of dispensing errors of about 10%, even in hospitals with advanced medication distribution systems, such as unit doses (7,11) .

A few studies were carried out in Brazil, specifically on medication dispensing processes, and presented high rates of errors, above 10% (5,8) .

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“…The rate of errors is considered one of the best indicators of quality of medication distribution systems and is still used to evaluate the safety of these systems (4,6,9) .…”