Peth reported possible causes of medication errors in the Emergency Department. These are divided along the stages of the medication process, including the dosing and dispensing themedication. The authors are from the University of Missouri.

Safety checks on dosing:

(1) double check on arithmetic

(2) double check the decimal point

(3) double check the patient's weight

(4) double check drug units


Safety checks on patient:

(1) double check allergy history

(2) double check identity, always checking the identification band prior to starting the dose


Safety checks for drugs dispensed in the Emergency Department:

(1) proper documentation of drugs being dispensed and administered, especially narcotics

(2) double check on drug and dose dispensed

(3) limit the amount dispensed to only provide coverage for the emergency


Additional practices:

(1) use of bar codes whenever possible

(2) prescriptions should only be filled that are complete and without questions



• Double checks should involve at least 2 people providing independent reviews.

• The prescribing provider should not be the person to dispense the medication.

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