Many hospitals have two standards of control for dispensing needed medications to patients. In the preferred standard, medication orders are screened for appropriateness by nurses and pharmacists before doses are prepared, checked and dispensed by a pharmacist in unit-dose form.
Drugs dispensed by the pharmacy are subject to a system of redundant independent checks.
In the other standard, with looser controls, medications are stored in patient care areas and removed as needed. No order screening takes place in the pharmacy. No system of independent redundant checks exists. This may increase the risk of a serious error, especially if drug product labeling is misunderstood. This makes it appear to some as though only 50 mg PE is in the vial.