The most frequently reported medical incidents were drug-related and made by nurses. Excessive dosing can cause adverse reactions and possibly lead to patient deaths. On the other hand, underdosing can delay treatment and prolong hospitalization. We investigated drugs associated with and factors leading to excessive dosing or underdosing incidents to clarify when pharmacists should intervene to reduce medication-related incidents. We analyzed incident reports collected by the Japan Council for Quality Health Care between January 2009 and June 2015. In total, we found 3,024 cases of excessive dosing and 2,119 cases of underdosing. In the excessive dosing group, dosing errors and the administration of an excessive dose without an order to do so comprised 785 cases and 482 cases, respectively. In the underdosing group, there were 902 cases of dosing errors and 366 cases where the dose was discontinued too early. We used logistic-regression analysis to compare cases of causative drugs and incident factors with dosing errors and other medical incidents. Our analysis revealed that there was a significant association between steroids, narcotic analgesics, antibacterial drugs and both excessive dosing and underdosing incidents. Also, there was a significant association between nurses not confirming the correct dose and misdosing incidents. It is easy for dosing errors to occur with the aforementioned drugs because the correct dosage varies with the patient s age, renal function, overall condition, and test results. These findings suggest that pharmacists in hospital wards need to check the correct dosage before administering the medication to prevent dosing errors.

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