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sociální a klinické farmacie Úvod: Zdravotní péče je inherentně spojena s rizikem poškození zdraví pacientů. Především pochybení spojené s farmakoterapií je častým typem hlášených nežádoucích událostí. Analýzou kořenových příčin medikačních chyb lze navrhnout efektivní preventivně nápravná opatření snižující pravděpodobnost jejich výskytu. Cílem studie bylo identifikovat důvody pochybení při podávání léčiv sestrami, popsat bariéry v jejich hlášení a přinést odhadovaný počet skutečně nahlášených pochybení. Metodika: Design empirického šetření byl založen na kvantitativní metodě, prostřednictvím standardizovaného dotazníku Medication Administration Error Survey (MAE survey). Výzkumné studie se zúčastnilo 112 sester ze čtyř nemocnic Jihočeského kraje.

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A medication error is one of the most common causes of patients’ complications or death in healthcare facilities. In the United States, 7,000 out of 9,000 patients die because of medication errors each year. Known factors are generally divided into four groups – human factor, intervention, technical factor, and system. Our study includes 17 studies from the OVID, Web of Science, Scopus, and EBSCO databases, in the range of 2015–2020. After a selection of professional publications, 2 categories were created – factors leading to medication errors and interventions to reduce medication error and testing their effectiveness. It has been found that human factor always plays a role, often supported by a poorly set-up system. The most mistakes are made in documentation, administration technique or accidental interchange of patients. The most frequently mentioned factors include nurses’ overload, high number of critically ill patients, interruptions in the preparation or in the administration of medications, absence of the adverse event reporting system, non-compliance with guidelines, fear, and anxiety. Another evidence of medication error is in the application of intravenous drugs, where an interchange of drugs or patients due to interruption occurs as well. Sufficient education of nurses and an adequate system of preparation and administration of drugs, for example using bar codes, are considered as an appropriate intervention.

The administration of medicines is a well-known risk factor associated with patient safety. Handling medicines is a routine daily activity for nurses. As such, nurses need to know basic information about how medicines are administered, as well as medicine storage, labeling, security, documentation, and how to dispose of unused medicines. As part of a standardized, controlled interview, we examined the knowledge base of nurses relative to the items list above. We also examined daily routines and habits relative to this topic.Our sample consisted of 1,202 nurses, who were representative of nurses in health care facilities, in terms of region and age, in the Czech Republic. The sample included nurses from a variety of hospital types.Most nurses (67.5%) reported that in their workplaces, doctors were only allowed to verbally-prescribe drugs under special circumstances. Roughly the same percentage of nurses were able to correctly identify the risk categories of drugs. However, only 10% of nurses knew the correct temperature for drug storage. A majority (64.9%) regularly checked drug expiration dates (once a week). Most nurses (72.6%) reported that they never prepared medications taken multiple times per day, in advance.Based on the results of our survey, nurses have a good understanding of how to handle and dispense medication; nonetheless, we found considerable room for improvement. Proper drug handling and administration are critically important for patient safety, and any omission or failure in these protocols can have serious or even fatal consequences.