Errors in Preparing and Dispensing Liquid Medications Are Common

Errors in reconstituting and dispensing oral medications pose safety and therapeutic threats. Investigators in France prospectively examined 100 caregivers as they reconstituted and prepared doses of oral amoxicillin or josamycin from powder. Before caregivers were asked to prepare the medication, they were given pamphlets with information about reconstitution and preparation using a dosing spoon for amoxicillin and dose-weight pipette for josamycin.

Only 31% of the caregivers read the information provided by the pharmacist. Reconstitution errors occurred in 46% of amoxicillin preparations and 56% of josamycin preparations. Most reconstitution errors with amoxicillin led to underdosing (32%) because bottles were filled with too much water. M…