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The rate of errors is considered one of the best indicators of quality of medication distribution systems and is still used to evaluate the safety of these systems (4,6,9) .
Some studies, published in the United States and England, showed an incidence of dispensing errors of about 10%, even in hospitals with advanced medication distribution systems, such as unit doses (7,11) .
A few studies were carried out in Brazil, specifically on medication dispensing processes, and presented high rates of errors, above 10% (5,8) .