Facilities and Difficulties of Health Professionals Regarding the Adverse Event Reporting Process

Mascarenhas, Franciane Aceli de Souza; Anders, Jane Cristina; Gelbcke, Francine Lima; Lanzoni, Gabriela Marcellino de Melo; Ilha, Patrícia

doi:10.1590/1980-265x-tce-2018-0040

Cited by 11 publications

(7 citation statements)

References 19 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Estudos indicam que a subnotificação ainda é sustentada pela vergonha e medo da cultura de segurança frágil e de ações punitivas (Jesus, Morais, & Almeida, 2020;Mourão & Oliveira, 2019), além do descaso dos profissionais e da sobrecarga de trabalho (Mascarenhas, Anders, Gelbcke, Lanzoni, & Ilha, 2019). Esses fatores também refletem a realidade da instituição em questão, no entanto, a cultura punitiva está sendo elucidada através de treinamentos rotineiros com as equipes e da realização de feedback com as partes envolvidas nas notificações.…”

Section: Resultsunclassified

O papel do farmacêutico na prevenção de erros de medicação

Ferreira

Pereira

Souza

et al. 2021

RSD

View full text Add to dashboard Cite

Visando a promoção de práticas seguras e a geração de indicadores para o monitoramento e avaliação do processo da utilização dos medicamentos, o objetivo deste trabalho foi identificar os erros de prescrição e dispensação evitados pela equipe farmacêutica a fim de contribuir para a qualidade do serviço. Trata-se de uma análise transversal realizada na farmácia central em um hospital escola no período de 01 janeiro a 31 dezembro de 2019. Foram avaliados os registros de intervenções farmacêuticas e da conferência das medicações antes da dispensação. Os dados coletados produziram indicadores que foram analisados através do Diagrama de Pareto e confrontados com os eventos notificados na instituição. Os erros de prescrição mais detectados pela intervenção farmacêutica foram a frequência e a dose inadequada. Os erros prevenidos durante a conferência dos pacotes de medicações foram a falta de medicamento prescrito e troca de horário. Além disso, das notificações relacionadas aos erros de medicação, foram observados que 32,88% eram referentes aos erros de prescrição, 41,10% aos erros de dispensação e 26,03% aos erros de administração. Mesmo com a subnotificação, foram registrados 3343 eventos prevenidos pela equipe farmacêutica, mostrando que sua atuação é indispensável e faz parte das estratégias de prevenção de eventos adversos no âmbito hospitalar.

show abstract

Section: Resultsunclassified

O papel do farmacêutico na prevenção de erros de medicação

Ferreira

Pereira

Souza

et al. 2021

RSD

View full text Add to dashboard Cite

show abstract

“…ADR underreporting is a worldwide problem which limits our results. Several studies 35,36,37,38 indicate that underreporting is caused by the lack of knowledge about the process of notifying or identifying ADRs, insecurity, busy work routine, lack of interest, lack of incentive, guilt for having possibly harmed the patient, or the feeling that only safe drugs are allowed on the market. Many of these reasons overlap with the "seven deadly sins" list created by William Inman in the 1980s.…”

Section: Discussionmentioning

confidence: 99%

Sales of “COVID kit” drugs and adverse drug reactions reported by the Brazilian Health Regulatory Agency

et al. 2022

View full text Add to dashboard Cite

Off-label use of azithromycin, hydroxychloroquine, and ivermectin (the “COVID kit”) has been suggested for COVID-19 treatment in Brazil without clinical or scientific evidence of efficacy. These drugs have known adverse drug reactions (ADR). This study aimed to analyze if the sales of drugs in the “COVID kit” are correlated to the reported number of ADR after the COVID-19 pandemic began. Data was obtained from the Brazilian Health Regulatory Agency (Anvisa) website on reported sales and ADRs for azithromycin, hydroxychloroquine, and ivermectin for all Brazilian states. The period from March 2019 to February 2020 (before the pandemic) was compared to that from March 2020 to February 2021 (during the pandemic). Trend adjustment was performed for time series data and cross-correlation analysis to investigate correlation between sales and ADR within the same month (lag 0) and in the following months (lag 1 and lag 2). Spearman’s correlation coefficient was used to assess the magnitude of the correlations. After the pandemic onset, sales of all investigated drugs increased significantly (69.75% for azithromycin, 10,856,481.39% for hydroxychloroquine, and 12,291,129.32% for ivermectin). ADR levels of all medications but azithromycin were zero before the pandemic, but increased after its onset. Cross-correlation analysis was significant in lag 1 for all drugs nationwide. Spearman’s correlation was moderate for azithromycin and hydroxychloroquine but absent for ivermectin. Data must be interpreted cautiously since no active search for ADR was performed. Our results show that the increased and indiscriminate use of ”COVID kit“ during the pandemic correlates to an increased occurrence of ADRs.

show abstract

“…Generally, most RACFs try to underreport any adverse events, which might affect their quality ratings and reputation in the community. 41 , 42 Kapoor 43 reported that the prevalence of adverse events in patients transitioning from hospitals to long-term care facilities was 37.3%. According to a study by Health and Human Services Inspector General Office, about 22% of older adults experienced at least one adverse event during their stay in the nursing home, and the total cost leading to rehospitalization was about USD 208 million.…”

Section: Discussionmentioning

confidence: 99%

Adverse Events and Risk Management in Residential Aged Care Facilities: A Cross-Sectional Study in Hunan, China

Li¹,

Shi²

2022

RMHP

View full text Add to dashboard Cite

Purpose Adverse events threaten residents’ safety. Risk management is important to provide proper care and maintain quality in residential aged care facilities (RACFs). However, there is little data on adverse events, risk management, and risk early warning in RACFs in the Chinese mainland. This study aimed to fill this gap by investigating the prevalence of the aforementioned aspects and related factors in China. Participants and Methods Using a cross-sectional design, a field survey of 272 RACFs in Hunan Province was conducted from January 25 to June 1, 2020. Data were collected using four main tools on prevalence of nursing adverse events, risk management, risk early warning, and general information. Descriptive statistics were described by frequency (percentage) and median (interquartile range). Mann–Whitney U -test and Kruskal–Wallis H -test, and Spearman coefficient were used for statistical analysis. Results RACFs experienced an average of five (15) adverse events in 2019, with falls and pressure ulcers being the most common. The total average score of risk management in RACFs was 4.72 (0.98) out of 5, with the environment and personnel management dimensions scoring the highest with 4.75 (1) and the service management dimension scoring the lowest with 4.60 (1). Only 72.79% had trained their staff on ethical and legal knowledge and 84.56% had utilized pre-hospital first aid. Further, 30% to 40% were unprepared for contingency plans of suicide, electric shock, gas poisoning, and drowning. There were significant risk management differences among the following variables: facilities’ locations, accreditation with the Practice Certificate of Social Welfare Facilities, bed-size, nursing hours per resident day, requirement for nursing staff with certificates, and payment for nursing staff (p < 0.05). Conclusion RACFs are facing safety challenges with a high prevalence of nursing adverse events. These facilities need to improve risk early warning and management to ensure residents’ safety.

show abstract

Facilities and Difficulties of Health Professionals Regarding the Adverse Event Reporting Process

Cited by 11 publications

References 19 publications

O papel do farmacêutico na prevenção de erros de medicação

O papel do farmacêutico na prevenção de erros de medicação

Sales of “COVID kit” drugs and adverse drug reactions reported by the Brazilian Health Regulatory Agency

Adverse Events and Risk Management in Residential Aged Care Facilities: A Cross-Sectional Study in Hunan, China

Contact Info

Product

Resources

About