There is a need to develop a culture of safety and quality in patient care. An understanding of the profile of ME types and frequencies in an institution is fundamental to raise awareness and implement measures to avoid them. Structural and procedural changes in hospital organization, with a focus on the efficacy, efficiency, and effectiveness of the medication system are needed to reduce MEs.

RESUMOA notificação dos erros de medicação é um instrumento importante para o gerenciamento da qualidade da assistência e segurança do paciente. Este estudo objetivou verificar junto à equipe de enfermagem o seu entendimento do que é um erro de medicação e apresentar a sua opinião quanto à notificação deste evento. Foi realizada um survey descritivo/exploratória com 89 profissionais cujos resultados demonstraram uma ausência de uniformidade na compreensão do que é um erro de medicação e quando ele deve ser notificado ao médico ou preenchido o relatório de ocorrências. Concluímos que há necessidade de se desenvolver programas educacionais que elucidem o que são os erros de medicação, discutindo cenários para entender as causas do problema com propostas de melhoria. Descritores: Erros de medicação; Qualidade; Gerenciamento de segurança; Enfermagem. ABSTRACT Notifying medication errors is an important instrument in managing assistance INTRODUÇÃOO erro, como e por que acontece, seja na área da saúde ou em qualquer outra, abre um leque de possibilidades para estudos relacionados à mente humana e seu aspecto cognitivo, como também, para análise das circunstâncias externas e fatores ambientais.Os erros podem trazer danos e prejuízos diversos a um paciente, desde o aumento do tempo de permanência em uma instituição hospitalar, necessidade de intervenções diagnósticas e terapêuticas e trazer, até, conseqüências trágicas, como a morte. São conhecidos como eventos iatrogênicos (1) . A palavra iatrogenia é de origem grega e deriva de iatrós que significa médico e gênesis que significa origem (2) . Nos primórdios da história da saúde, os eventos iatrogênicos estavam vinculados à atuação médica. No entanto, nos dias de hoje, seu significado tem uma dimensão maior, definida como a "ação

Objective: To analyze medication errors notified at a pediatric teaching hospital in São Paulo city. Methods: Retrospective and descriptive study in which 120 error events and 115 spontaneous notifications were analyzed, between January 2007 and December 2008. Results: The error rate was 1.15 per 1000 patients-day; 27.5% of notifications referred to the school age range and the Pediatric ICU was the sector with most notifications. The error type related to wrong infusion speed predominated (25%). The human factor dimension in the performance deficit category (54%) was the most frequent cause of error events. Conclusion: The safety culture is a continuous process in institutions and the notification of adverse events is part of the strategies. Improvement measures should be incorporated based on their analysis, whether related to the review of the work process or to team training

This study was intended to analyze pedagogic projects of undergraduate courses in Nursing, Pharmacy, Physiotherapy, and Medicine in the Federal University of Sao Paulo, in order to appraise the contents of patient safety teaching in those courses. The study is of descriptive and exploratory nature using as strategy a documental review. The documents analyzed were the Pedagogic Projects of the courses. The teaching contents on patient safety were found to be fragmented, without the depth and conceptual scope recommended by the World Health Organization (WHO) guidelines. Each course highlights the specific topics related to the pretended formative process. Inserting and trying to unify the contents on patient safety is still in its beginning in Brazilian schools and it is not present in the educational objectives. There is a need of reviewing the curricula using an interdisciplinary and trans disciplinary approach to develop this topic. IntroductionFuture professionals face ever-growing challenges in all areas of training, with great complexity and importance not only according to the contents of what is taught in Universities, but specially for what is the aim of this activity: a student with an adequate education. Not withstanding these growing challenges, the university structure is still based in an educational practice based in traditional principles, thus causing an imbalance between the discursive statements, the daily practice, and the demands in the human and professional training field 1 .The need to communicate complex albeit important knowledge to students, relevant within and to professional practice, has promoted a debate about the kind of knowledge needed and basic for the professional practice in different areas of activity, and specifically in health. This debate concludes in the need of developing a curriculum that may be conducive to let the educational subjects to build significant knowledge, developing diverse competencies and skills and helping to train reflective professionals with criticism in order to exert leadership and aiming to community welfare 2 .From an historical point of view, the curriculum is power, place and territory of subjects and programmatic contents, defined among other factors through ideological biases of the faculty of each discipline 1,3 .Nevertheless, contemporaneity and the educational transformations it carries in itself, are to be considered in order to deal with the technological, pharmacological, political, social and health care transformations, that force to rethink contents for a curriculum that may include whatever may be needed to be known by the students.These curricula must be designed to foster critical and reflective thinking and a transformational practice 4 .In this context, both teachers and practitioners involved in activities directly in contact with patients have debated in Brazil and in the international milieu about the education of these future professionals and how to prepare them for a safe practice in the daily patient care 5 . COMUNICAÇÃO ...

Objective: To assess the incidence of adverse events and associate them with nursing workload, nursing team staffing and the severity of the patients. Method: A quantitave, cross-sectional, prospective study was conducted with 304 consecutive patients admitted to the General Intensive Care Unit of a private hospital between September and December 2013 (four months). Results: There were 39 adverse events, and the most prevalent was pressure sore. Patients who presented an event had a higher mean age, higher prevalence of clinical admissions, longer hospital stay, higher scores in the Acute Physiology and Chronic Health Evaluation (APACHE) II and in the Nursing Activities Score (NAS) and lower score in the Braden scale and in the Glasgow scale. There was no significant difference regarding nursing team staffing. Conclusion: There was a higher incidence of adverse events in patients who presented a profile of greater risk and severity identified by predictive scales. ResumoObjetivo: Avaliar a incidência de eventos adversos e associá-los com a carga de trabalho de enfermagem, o dimensionamento da equipe de enfermagem e o perfil de gravidade do paciente. Métodos: Foi realizado um estudo transversal, prospectivo, com abordagem quantitativa, em 304 pacientes consecutivos internados em Unidade de Terapia Intensiva geral de um hospital privado, admitidos entre setembro e dezembro de 2013 (quatro meses). Resultados: Ocorreram 39 eventos adversos sendo a lesão por pressão a mais prevalente. Os pacientes que apresentaram algum evento tiveram maior média de idade, maior prevalência de internações clínicas, internações mais prolongadas, maior escala Acute Physiology and Chronic Health Evaluation (APACHE) II, maior pontuação do Nursing Activities Score (NAS), menor escore na escala de Braden e menor escala de Glasgow e não tiveram diferenças significantes em relação ao dimensionamento da equipe de enfermagem. Conclusão: Houve maior incidência de eventos adversos em pacientes que exibiram um perfil de maior risco e gravidade identificados por meio de escalas preditoras.