Erros de medicação: tipos, fatores causais e providências tomadas em quatro hospitais brasileiros

Abstract

This study analyzed the causes, types, administrative measures taken and suggestions concerning medication errors according to the perspective of professionals involved with the medication systems in four Brazilian hospitals. It is an exploratory, survey-type, multicentric study. The sample consisted of professionals from the medical clinic and pharmacy in the above-mentioned hospitals. Semistructured interviews were used for data collection. Results showed that the most frequently error types mentioned by the professionals were related to medication ordering/transcription. Lack of attention, individual mistakes and problems in service management were the major causes of errors. Reports were the main measures taken in view of errors, and changes in individual attitudes were the most frequently mentioned form to prevent them.

Patient safety in care circumstances: prevention of adverse events in the hospitalization of children

“…Many studies report the incidence of adverse events in the practice of health care internationally (1,(9)(10)(11) . Even though the specificities of studies hinder comparison or replication in multiple contexts, all present similar conclusions related to the prevention of adverse events (9) .…”

“…However, studies concerning adverse events involving medication address many stages in this process and include in the results other actors such as pharmacists, physicians, pharmacy technicians, and others (14)(15) . The complexity that involves the medication process, from the writing of a prescription up to its administration, needs to be reviewed by healthcare workers because it is an activity exclusive to them, which requires precision, responsibility and scientific knowledge to avoid such adverse events.…”

Prescription errors in Brazilian hospitals: a multi-centre exploratory survey

“…It may cause confusion, which goes against the Brazilian medical ethics code which establishes that the doctor is responsible for prescribing clearly and legibly and, therefore, without erasures 40 . Despite this, previous studies showed that erasures are common in Brazilian prescriptions 13,20,35 . Sometimes a 'free text' feature can be used to substitute erasures in prescriptions.…”

“…The discussion about medication errors in Brazil is still incipient and few articles have been published 1,2,12,13 . Medication errors accounted for 50% of adverse events detected in a study carried out in a private hospital in the city of Campinas (São Paulo State) 14 .…”

Ocorrências éticas com profissionais de enfermagem: um estudo quantitativo

“…Nessa perspectiva, a negligência, falhas individuais e problemas na administração de serviços constituem-se em importantes atributos das causas de erros, cometidos pelos profissionais de enfermagem, no que tange ao preparo e administração de medicamentos (20) .…”