Identificação de erros na dispensação de medicamentos em um hospital oncológico

Medication errors are now considered a public health problem, because error is a matter difficult to approach and often discussions are directed to the responsibility of the guilty and don’t provide opportunities to improve the system in order to prevent failures. Objective: To evaluate drug dispensing system, identifying the main content errors during screening and dispensing of prescription order forms to patients in an oncology hospital. Method: a prospective cross-sectional study of medication errors found during drug screening and dispensing of 5300 handwritten and typed prescriptions during the period August to October 2010. The dispensations were checked about content errors: higher dose than necessary, lower dose than necessary, dose omission, wrong medications dispensed, medications dispensed in wrong pharmaceutical form. Results: There were 551 dispensing errors according to the adopted classification system (content errors), which represents 10.39% of the total number of doses dispensed during the study period. These errors were distributed as follows: 16.33% of higher dose than necessary (risk of toxicity), 28.13% of lower dose than necessary (sub-dose), 35.93% of dose omission (forgetfulness), 17.24% of wrong drug dispensed (another drug) and 2.35% of drug dispensed in wrong pharmaceutical form. Conclusions: We observed that the frequency of dispensing errors in this study was significant, indicating that the implementation of secure, organized and effective systems, as automation in the dispensation, is essential to minimize errors. Thus, it is necessary the introduction of a continuous process of training employees and the implementation of the dispensing validation process by the pharmacist.