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Medication Dispensing Errors and Prevention

Jakub MusiaƂek

May 9, 2023

Navigating the Pitfalls: A Proactive Approach to Minimizing Medication Dispensing Mistakes

In may of 2023 , there was a fresh publication which aims to tackle medication errors by identifying their most common types and pinpointing the critical stages where they are likely to occur. It also proposes strategies for preventing these errors and discusses how interprofessional teams can collaborate to reduce medication-related mistakes. The authors identified:

  • Medication Error

  • Adverse Drug Reaction

  • Adverse Drug Event

  • Medication Misadventure

  • Sentinel Event


There are following three takeaways from this publication:

  1. Medication dispensing errors are a common and serious problem. Medication errors are estimated to cause 7,000 to 9,000 deaths in the United States each year, and they cost the healthcare system =~ 40 billions of dollars each year. Additionaly hundreds of thousands of patients experience adverse reactions or complications related to medications, many of which go unreported. This highlights the need for improved monitoring and reporting systems to capture these incidents and enhance patient safety.

  2. Medication dispensing errors can occur at any point in the medication use process. Common types of medication dispensing errors include giving the wrong dose, giving the wrong drug, giving the drug at the wrong time, omitting a dose, and administering the drug incorrectly.

  3. There are a number of strategies that can be used to prevent medication dispensing errors. These strategies include using computerized physician order entry (CPOE) systems, bar-coded medication administration systems, and other safety technologies; implementing medication safety programs and training for healthcare staff; and educating patients about their medications and how to take them safely.


Following publication share an insight how we can tacle those problem, here is a summarization for most important one and how ADC can help you overcome those problems:

  1. Verify High-Alert Medications: Double-check dosing and frequency for high-alert medications.

    ADC Support: Automate alerts for high-risk medications to ensure an extra layer of verification.

  2. Consult Pharmacists for Uncertainty: Speak to a pharmacist if uncertain about drug or dose.

    ADC Support: Integrate real-time consultation features to facilitate immediate clarification.

  3. Confirm Dose and Frequency: Check if unsure about the dose or frequency.

    ADC Support: Provide easily accessible drug information databases.

  4. Include Age and Weight: Add patient's age and weight on each prescription. ADC Support: Auto-fill these details from patient records.

  5. Check Organ Function: Validate liver and renal function before ordering medication. ADC Support: Automated alerts based on latest test results.

  6. State the Condition: Specify what condition is being treated when prescribing.

    ADC Support: Auto-fill potential diagnoses based on patient history.


Base on the following publication: https://www.ncbi.nlm.nih.gov/books/NBK519065/

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