Revelação da ocorrência de erro de medicação em unidade de cuidados intensivos pediátricos

RESUMOA segurança do paciente constitui problema de saúde pública, e erros com medicamentos são os mais freqüentes e graves. O artigo apresenta características epidemiológicas dos erros de medicação em diferentes áreas de atendimento pediátrico, e aponta estratégias de prevenção. Aproximadamente 8% das pesquisas sobre erros de medicação identificadas em bases de dados nacionais e internacionais referem-se à população pediátrica. Crianças apresentam maior vulnerabilidade à ocorrência de erros devido a fatores intrínsecos, destacando-se características anatômicas e fisiológicas; e extrínsecos, relativos à falta de políticas de saúde e da indústria farmacêutica voltadas ao atendimento de tais especificidades. As evidências apontam para a necessidade de implementação de estratégias de prevenção de erros de medicação, contribuindo para promover a segurança do paciente. descritores: Erros de medicação; Pediatria; Segurança; Qualidade da Assistência à Saúde. ABSTRACT Concerns regarding patient safety affect healthcare, and medication errors are the most frequent category of medical errors and linked with severe consequences. This study discusses epidemiologic characteristics of medication errors in pediatric patients and points out prevention strategies. Approximately 8% of the studies on the subject of medication errors identified in different national and international databases are distinctively related to the pediatric population. Children are vulnerable to medication errors due to intrinsic factors, such as proper anatomic and physiological characteristics; and due to extrinsic factors, with emphasis on the lack of public health politics and changes in the pharmaceutical industry to attend children's needs. The available evidences indicate, as imperative, the implementation of strategies to prevent medication errors, contributing to promote patient safety. Key words: Medication errors; Pediatric; Safety; Quality of Health Care. RESUMEN La seguridad del paciente es un problema de salud pública y los errores con medicamentos son los más frecuentes y más graves. Este artículo describe características epidemiológicas de errores de medicación en áreas de atención pediátrica y algunas estrategias de prevención. Aproximadamente 8% de las investigaciones sobre errores de medicación identificadas en las bases de datos nacionales e internacionales se refieren específicamente a niños. Los niños tienen mayor vulnerabilidad a la ocurrencia de errores debidos a factores intrínsecos, con destaque para características anatómicas y fisiológicas, e extrínsecos, en particular con respecto a falta de políticas sanitarias y de la industria farmacéutica orientada a la atención de tales características. Evidencias muestran la necesidad de aplicar estrategias para prevenir errores de medicación, promoviendo la seguridad del paciente. descriptores: Errores de medicación; Pediatría; Seguridad; Calidad de la Atención de Salud. erros de medicação em Pediatria

In an institution without adverse events report and a formal system to patient safety analysis, the implementation of a local nonpunitive approach to medication errors notification represented an important tool to patient safety promotion.

Objective: To investigate the variability in the establishment of the midaxillary line as external reference point (ERP), by different healthcare workers, for the measurement of central venous pressure in children.Methods: Descriptive and correlational study carried out in a pediatric intensive care unit of a teaching hospital. During the establishment of the midaxillary line as ERP for central venous pressure measurement, five assessments of the same patient made by healthcare workers and one assessment made by a trained evaluator were compared. A total of 120 assessments were made by 44 healthcare workers, 17 (38.6%) by nursing assistants and nursing technicians, 16 (36.3%) by nurses and 11 (25.1%) by physicians, in addition to 24 assessments made by the trained evaluator. The data were analyzed using the chi-square test, ANOVA, Kruskal-Wallis test and t test. Significance level was set at 5%.Results: There was statistically significant difference between the assessments made by healthcare workers and by the evaluator (p < 0.001). The comparison of the variability in the measurements made by healthcare workers revealed that 56 (46.7%) measurements were lower than those obtained by the evaluator (range from -0.5 to -9), 44 (36.7%) were higher (range from 0.5 to 4) and 20 (16.7%) were concordant (zero variability). Professional category did not influence the concordance between the ERPs (p = 0.899), or the variability observed (p = 0.778). However, the measurements made by professionals with greater experience in intensive care tended to differ more sharply from those made by the evaluators. Conclusion:The indications of the midaxillary line as ERP presented variations when measured by the healthcare team and by the trained evaluator. Variability was not influenced by professional category, and the more experienced the healthcare worker, the greater the probability for underestimation of the ERP. According to the results of this study, such situations may compromise both the efficacy of this procedure and patient safety.

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