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Analysis of discrepancies in unit-dose distribution at a US hospital suggests missed doses are common

Analysis of unit-dose discrepancies at a 700-bed public teaching hospital in Chicago, USA, revealed rates of medication error significantly higher than those measured by other hospitals, principally because the system was failing to deliver the needed doses at the appropriate time.(1)     A total of 23 patients were followed for 183 days. The length of hospital stay ranged from 3 days to 18 days; the number of scheduled medications a patient received during hospitalisation ranged from 4 to 18; and the number of scheduled doses per day ranged from 5 to 18. The frequency of missed doses was assessed by comparing the medications delivered to each patient with the medications documented on the medication administration record.

Of 1,992 doses examined, of which 1,839 were physician-ordered and 153 were unordered doses, the researchers found a discrepancy rate of 19.6%. Dose discrepancies included missing doses (56% of discrepancies), doses returned to the pharmacy without a reason (34%), and presumed administration of unordered medications (10%). Neither length of stay nor number of medications prescribed influenced discrepancy rate. There was a trend towards a higher discrepancy rate when the number of prescribed doses per day was 10 or greater.

As a result of this study, a multidisciplinary committee was set up to discuss how to improve the delivery and administration of medications to patients.


  1. Max BE, Itokazu LH, Danziger LH, Weinstein RA. Assessing unit dose ­discrepancies. Am J Health-Syst Pharm 2002;59(9):856-8.

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