Concomitant prescribing and dispensing errors at a Brazilian hospital: a descriptive study.
OBJECTIVE
To analyze the prevalence and types of prescribing and dispensing errors occurring with high-alert medications and to propose preventive measures to avoid errors with these medications.


BACKGROUND
The prevalence of adverse events in health care has increased, and medication errors are probably the most common cause of these events. Pediatric patients are known to be a high-risk group and are an important target in medication error prevention.


METHODS
Observers collected data on prescribing and dispensing errors occurring with high-alert medications for pediatric inpatients in a university hospital. In addition to classifying the types of error that occurred, we identified cases of concomitant prescribing and dispensing errors.


RESULTS
One or more prescribing errors, totaling 1,632 errors, were found in 632 (89.6%) of the 705 high-alert medications that were prescribed and dispensed. We also identified at least one dispensing error in each high-alert medication dispensed, totaling 1,707 errors. Among these dispensing errors, 723 (42.4%) content errors occurred concomitantly with the prescribing errors. A subset of dispensing errors may have occurred because of poor prescription quality. The observed concomitancy should be examined carefully because improvements in the prescribing process could potentially prevent these problems.


CONCLUSIONS
The system of drug prescribing and dispensing at the hospital investigated in this study should be improved by incorporating the best practices of medication safety and preventing medication errors. High-alert medications may be used as triggers for improving the safety of the drug-utilization system.
Pharmacy Service, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil. mdgsilva@hc.ufmg.br
Maria das Dores Graciano
Md
Silva
Mário Borges
MB
Rosa
Bryony Dean
BD
Franklin
Adriano Max Moreira
AM
Reis
Lêni Márcia
LM
Anchieta
Joaquim Antônio César
JA
Mota
D001938:Brazil; D002648:Child; D003430:Cross-Sectional Studies; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data*; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control / Q000706:statistics & numerical data*; D008510:Medication Systems, Hospital / Q000706:statistics & numerical data; D004364:Pharmaceutical Preparations / Q000008:administration & dosage*; D010607:Pharmacy Service, Hospital / Q000706:statistics & numerical data
D004364:Pharmaceutical Preparations