Profile of dispensing errors according to the dispensing system adopted in a public hospital

Abstract

Medication errors are frequent and should be focus in the prevention of medication-related harm under a broad and systemic approach. In this context, the aim of the present study was to characterize the profile of dispensing errors in a public hospital in Belo Horizonte (MG), and to evaluate the association of its occurrence with the the dispensing system. For this purpose, a cross-sectional study was carried out at the pharmacy of the hospitalization unit. The frequency, type of error, and drug involved in the error (type of drug and whether it was a high-alert medication - HAM) were determined by dispensing system (profile I - single pack dispensed every 24 hours; profile II - single pack dispensed every 12 hours, profile III – individual packaging according to the administration time dispensed every 12 hours). The difference in the proportion of errors between the profiles was determined (Pearson’s chi-square test; statistical significance = 5%). A total of 726 prescriptions were analyzed, and in 109 of them (15%) 138 dispensing errors were found; 26 of these errors (n = 19%) involved a HAM. The most common error was ‘dose omission’ (n = 55; 40%). The drugs most involved in errors were metamizole (n = 26; 19%), metoclopramide (n = 14; 10%) and heparin (n = 10; 7%). The dispensing profile III presented a higher proportion of prescriptions with errors (n = 42; 16%). Regarding the dispensed items (n = 9,730), 3% of them presented an error (n = 268). Profile II was highlighted, with the highest proportion of items with errors (n = 114, 4%), which was superior to the other dispensing profiles (p <0.05). A high frequency of dispensing errors was detected among the prescription orders, highlighting the omission errors and the dispensation profile II.