Medication Distribution in Hospital: Errors Observed X Errors Perceived


  • G. N. Silva
  • M. A. R. Rissato
  • N. S. Romano-Lieber



medication errors, hospital medication system


Abstract: The aim of the present study was to compare errors committed in the distribution of medicationsat a hospital pharmacy with those perceived by staff members involved in the distributionprocess. Medications distributed to the medical and surgical wards were analyzed. The drugswere dispensed in individualized doses per patient, separated by administration time in boxes orplastic bags for 24 hours of care and using the carbon copy of the prescription. Nineteen staffmembers involved in the drug-dispensing process were also interviewed. In the observationphase, 1963 drugs dispensed in 259 prescriptions were analyzed, with a total of 61 dispensingerrors (3.2% of the medications). The most frequent errors were omission of the prescribedmedication (23%) and distribution of non-prescribed medication (14.8%). In the interviews, themain errors perceived by the staff were medications dispensed at a concentration other thanthat prescribed (22%) and the distribution of non-prescribed medication or medication differentfrom that prescribed (20%). Differences were found between the most frequent errors observedand those reported by staff members. Nonetheless, the views of the staff proved coherent withthe literature on this issue.

Keywords: medication errors, hospital medication system.


Anacleto T.A, Perini E, Rosa M.B, Medication errors and drug systems in the pharmacy. Clinics 2005;60(4):325-32

Barker K.N., Allan E.L. Research on drug-use-system errors. Am J Health Syst Pharm1995; 52(4):400-3.

Barker K.N., Kimbrought W., Heller W.M. A study of medication errors in hospital. Arkansas: University of Arkansas; 1966.

Barker K.N., McConnel W.E. The problem of detecting errors in hospitals. Am J Hosp Pharm1962; 19:360-9.

Beso A., Franklin B.D., Barber N. The frequency and potential causes of dispensing errors in a hospital pharmacy. Pharm World Sci. 2005; 27: 182-190.

Carvalho V.T., Cassiani S.H.B. Erros na medicação: anise das situações relatadas pelos profissionais de enfermagem. Medicina 2000; 33: 322-30.

Cina J L, Gandhi TK, Churchill W, Fanikos J, McCrea M, Mitton P, et al. Incidence and severity of medication dispensing errors in a hospital pharmacy. Jt Comm J Qual Patient Saf. 2006;32(2):73-80.

Guchelaar HJ, Colen HBB, Kalmeijer MD, Hudson PTW, Teepe-Twiss IM. Medication errors hospital pharmacist perspective. Drugs. 2005;65(13):1735-46.

Irwing A, Ross J, Seatonc J, Mearns K. Retrospective analysis of DATIX dispensing error reports from Scottish NHS hospitals. Int J Pharm Pract. 2011;19:417-23.

James KL, Barlow D, McArtney R, Hiom S, Roberts D, Whittlesea C. Incidence, type and causes of dispensing errors: a review of the literature. Int J Pharm Pract. 2009;17:9-30.




Como Citar

Silva, G. N., Rissato, M. A. R., & Romano-Lieber, N. S. (2013). Medication Distribution in Hospital: Errors Observed X Errors Perceived. Scientific Electronic Archives, 3, 45–48.

Artigos Semelhantes

Você também pode iniciar uma pesquisa avançada por similaridade para este artigo.