Strategies for preventing dispensing errors in hospital pharmacies: a literature reviewal pharmacies: a literature review
DOI:
https://doi.org/10.47456/hb.71.51130Keywords:
Medication errors, patient safety, rational use of medications, dispensing of medicationsAbstract
The hospital pharmacy plays an essential role in patient safety, being responsible for technical-care activities such as selection, storage and dispensing of medicines. Dispensing error, understood as the discrepancy between the prescribed and supplied medicine, is an avoidable incident with the potential to cause significant damage to health. This integrative literature review aimed to identify and systematize effective strategies for the prevention of dispensing errors in hospital pharmacies. The search was carried out in the PubMed and Virtual Health Library (BVS) databases and after applying the eligibility and exclusion criteria, five studies comprised this study. The results showed that the prevention of dispensing errors involves the combined use of light, light-hard and hard technologies. The most effective strategies included reviewing work processes, double-checking potentially hazardous drugs, e-prescribing, implementing automated dispensing systems, standardized patient identification, and strengthening institutional safety culture. The studies pointed to significant reductions in dispensing errors after the adoption of specific protocols and technologies. Automation, although associated with high costs, proved to be cost-effective in the long term, increasing traceability, operational efficiency and freeing up the pharmacist's time for clinical activities. However, no technology replaces the role of the pharmacist, considered essential in the drug chain and in the promotion of the rational use of medicines. Thus, it is concluded that the strengthening of process management, continuing education, multiprofessional integration and the planned incorporation of technologies are fundamental strategies to reduce dispensing errors and promote patient safety.
References
1. ANGONESI D; RENNÓ MUP. Dispensação farmacêutica: proposta de um modelo para a prática. Cien Saude Colet 16(9): 3883-3891, 2011.
2. BRASIL. Ministério da Saúde. Portaria nº 4.283, de 30 de dezembro de 2010. Aprova as diretrizes e estratégias para organização, fortalecimento e aprimoramento das ações e serviços de farmácia no âmbito dos hospitais. Diário Oficial da União, Brasília, 31 dez. 2010, Seção 1, p. 94. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2010/prt4283_30_12_2010.html. Acesso em 01 de agosto de 2025.
3. BERDOT S. A centralized automated-dispensing system in a French teaching hospital: return on investment and quality improvement. Int J Qual Health Care 31(3): 219-224, 2019.
4. CHEUNG KC, BOUVY ML, DE SMET PAG. Medication errors: the importance of safe dispensing. Br J Clin Pharmacol 67(6): 676-680, 2009.
5. DOMINICCI APA, LIMA GL, BALDONI AO, FIGUEIREDO AS, VIEIRA LB, MARQUES LAM, NOGUEIRA DA, REIS TM. Dispensing drugs: knowledge of patients/caregivers and profile of responsible for the service. Res Soc Dev 11(3):e53411326782, 2022, doi:10.33448/rsd-v11i3.26782.
6. GALATO D, ALANO GM, TRAUTHMAN SC, VIEIRA AC. A dispensação de medicamentos: uma reflexão sobre o processo para prevenção, identificação e resolução de problemas relacionados à farmacoterapia. Rev Bras Cienc Farm 44(3): 466-473, 2008.
7. GAO Y, GUO Y, ZHENG M, HE L, GUO M, JIN Z, FAN P. A refined management system focusing on medication dispensing errors: A 14 year retrospective study of a hospital outpatient pharmacy. Saudi Pharm J 31(2): 101845, 2023, doi:10.1016/j.jsps.2023.101845.
8. LEITE NMS, VIEIRA FS. Avaliação da assistência farmacêutica de um hospital público especializado em hematologia: resultados e contribuição aos estudos avaliativos em saúde. Tempus Actas Saude Colet 17(3): 20-30, 2025.
9. LINDENMEYER LP, GOULART VP, HEGELE V. Reconciliação medicamentosa como estratégia para a segurança do paciente oncológico - resultado de um estudo piloto. Rev. Bras. Farm. Hosp. Serv. Saúde São Paulo 3(4): 51-55, 2013.
10. MAGALHÃES AMM, MOURA GMSS, PASIN SS, FUNCKE LB, PARDAL BM, KRELING A. Processos de medicação, carga de trabalho e a segurança do paciente em unidades de internação. Rev Esc Enferm USP 49(Especial): 42-49, 2015.
11. MAIA JLB, BATISTA RFL, ROSA MB, MELO JB, SILVA FM, CARNEIRO S. Fatores associados a erros de dispensação de medicamentos: contribuição à melhoria de sistemas de medicação. Rev Enferm UERJ 27: e44633, 2019, doi:10.12957/reuerj.2019.44633.
12. MARDANI A, NAZARI R, MOHEBBI H, HASSANIA Z, HOSSEINZADEH A. Medication errors and barriers to reporting in a large teaching hospital in southern Iran: A cross-sectional study. Saudi Pharm J 31(10): 1220-1226, 2023.
13. MENDES KDS, SILVEIRA RCCP, GALVÃO CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & Contexto Enferm 17(4): 758-764, 2008.
14. ORGANIZAÇÃO MUNDIAL DA SAÚDE. OMS. Global Patient Safety Challenge, 2017. Disponível em: https://iris.who.int/server/api/core/bitstreams/15520c4f-89d1-4a8f-9bab-6b771aa30acb/content. Acesso em 17 de julho de 2025.
15. SIRTOLI R, PINTO ECP, FIEIRA C, VOL KWEINS JG, PENTEADO SS, CALDEIRA LFC. Perfil e análise de pareto dos erros de dispensação de um hospital público. Rev Bras Farm Hosp Serv Saude 9(2): e092.007, 2018.
16. SZALADOS JE. Ethical and legal issues in contemporary pharmacy practice: scope of practice, drug use stewardship, medical error management, and teamwork. In: The Medical-Legal Aspects of Acute Care Medicine. Springer, 2021, p.437-452.
17. RADLEY DC, WASSERMAN MR, OLSHO LE, SHOEMAKER SJ, SPRANCA MD, BRADSHAW B. Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. J Am Med Inform Assoc 20(3): 470-476, 2013.
18. TELLERÍA I, FERRO-URIGUEN A, MIRÓ-ISASI B, MARTÍNEZ-ARRECHEA S, GENUA-GOENA MI. The impact of automation on the safety of drug dispensing in nursing homes. Farm Hosp 42(4): 141-146, 2018.
19. VILELA RP JERICÓ MC. Implantação de tecnologias para prevenção de erros de medicação em hospital de alta complexidade: análise de custos e resultados. Einstein (17): 4, eGS4621, 2019.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Lara Ferrarini Savergnini, Jefferson Pessoa Hemerly , Ana Alice Dias de Castro Luz
This work is licensed under a Creative Commons Attribution 4.0 International License.
All works published in the Brazilian Journal of Production Engineering (BJPE) are licensed under Creative Commons Attribution 4.0 International (CC BY 4.0).
This means that:
Anyone can copy, distribute, display, adapt, remix, and even commercially use the content published in the journal;
Provided that due credit is given to the authors and to BJPE as the original source;
No additional permission is required for reuse, as long as the license terms are respected.
This policy complies with the principles of open access, promoting the broad dissemination of scientific knowledge.
🔗 Click here to access the full license
