Concomitant prescribing and dispensing errors at a Brazilian hospital: a descriptive study

Area of Science:

• Pharmacovigilance
• Patient Safety
• Health Systems Research

Background:

• Medication errors are a leading cause of adverse health events.
• Pediatric patients are a vulnerable population at high risk for medication errors.

Purpose of the Study:

• To determine the frequency and nature of prescribing and dispensing errors involving high-alert medications in pediatric inpatients.
• To identify potential preventive strategies for these medication errors.

Main Methods:

• Observational study in a university hospital setting.
• Data collection on prescribing and dispensing errors for high-alert medications in pediatric inpatients.
• Classification of error types and identification of concomitant errors.

Main Results:

• A high prevalence of errors was observed: 89.6% of high-alert medications had prescribing errors (1,632 total).
• All dispensed high-alert medications had at least one dispensing error (1,707 total).
• Over 42% of dispensing errors were concomitant with prescribing errors, suggesting prescription quality impacts dispensing.

Conclusions:

• The drug prescribing and dispensing system requires enhancement to improve medication safety.
• High-alert medications can serve as indicators for systemic improvements in drug safety.
• Addressing prescription quality is crucial for reducing concomitant prescribing and dispensing errors.