• Maria das Dores Graciano Silva, Mário Borges Rosa, Bryony Dean Franklin, ReisAdriano Max MoreiraAM, Lêni Márcia Anchieta, and Joaquim Antônio César Mota.
• Pharmacy Service, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil. mdgsilva@hc.ufmg.br
• Clinics (Sao Paulo). 2011 Jan 1; 66 (10): 169116971691-7.

ObjectiveTo 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.IntroductionThe 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.MethodsObservers 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.ResultsOne 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.ConclusionThe 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.

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