Identificación Y Análisis De Los Errores De Medicación en Seis Hospitales Brasileños

Abstract

rEsumEnEsta investigación identificó, a través del método de observación directa, los errores de medicación ocurridos en unidades de clínica médica de seis hospitales brasileños. La muestra consistió de las dosis prescritas y administradas en las unidades y observadas durante el periodo de recolección de datos, obedeciendo a un mínimo de 35 dosis/día, durante 30 días. Los resultados evidenciaron los siguientes aspectos: el 1,7% de los medicamentos administrados fue diferente de los prescritos; el 4,8% de las dosis administradas difirieron de las prescritas; el 1,5% de los medicamentos fue administrado en vías diferentes de las prescritas; el 0,3% de los pacientes recibieron medicamentos no autorizados; cerca del 7,4% de los medicamentos fue administrado más de 1 h después del horario previsto y el 2,2% más de 1 h antes del prescrito.Palabras clave: Errores de medicación, seguridad del paciente, administración de medicamentos. abstractThis study identified medication errors that occurred at the medical clinics of 6 Brazilian hospitals, using direct observation. The sample consisted of doses prescribed and administered at the clinics, which were observed during the data collection period, respecting a minimum of 35 doses/day, during a 30-day period. The results evidenced that: 1.7% of the administered medication was different from the prescribed drugs; 4.8% of the administered doses were different from the prescriptions; 1.5% of the medication was administered through routes different from the prescriptions; 0.3% of patients received non-authorized medication; about 7.4% of the medication were administered more than 1 h after and 2.2% more than 1 h before the prescribed medication time.

Effects of the implementation of a preventive interventions program on the reduction of medication errors in critically ill adult patients

“…Different Latin-American studies have addressed the effect of individual interventions on specific stages of the medication management process [11][12][13][14][15][16]. However, there is no published information on the evaluation of a bundle of preventive measures, applied by a multidisciplinary team to all the stages of medication use.…”

“…Only a few studies conducted in Latin American countries allow the identification of part of the processes and causes most responsible for errors. Those studies have been carried out in hospitalized patients in Brazil [11][12][13], Mexico [14], Uruguay [15], and Argentina [16], reporting ME rates to a specific stage of medication process and different setting than adult ICU. In addition, medical record review has been the method mainly used for detecting MEs [17].…”

A study of medication errors during the prescription stage in the pediatric critical care services of a secondary-tertiary level public hospital

“…These findings demonstrate the wide variability of prescription rates in private vs public Mexican hospitals. In other countries with similar healthcare conditions to Latin America, one Brazilian study found a ME rate of 7.4% and Colombian study found a ME rate of 97.3% [36] with a follow-up publication estimating that 67.2% of these errors reach the patient [37,38]. The importance of this study demonstrates the need to include trained pharmacists to the healthcare team in Mexican public hospitals; to validate prescriptions, to provide prescription training to health care providers, and most importantly, to enhance drug safety.…”

“…These findings demonstrate the wide variability of prescription rates in private vs public Mexican hospitals. In other countries with similar healthcare conditions to Latin America, one Brazilian study found a ME rate of 7.4% and Colombian study found a ME rate of 97.3% [ 36 ] with a follow-up publication estimating that 67.2% of these errors reach the patient [ 37 , 38 ].…”

Conocimientos y prácticas de profesionales de la salud en uso de medicamentos

“…Con la revisión de la literatura, se identificó que existe una limitada evidencia que soporte los conocimientos y usos de medicamentos en vías y condiciones no establecidos en la ficha técnica; por tanto, no existe una definición clara y se presenta un desconocimiento en los profesionales de la salud (10,(13)(14)(15)17). Otras características comunes sobre los resultados de las investigaciones son: el uso fuera de etiqueta de forma común entre los pediatras, dado que existe falta de medicamentos específicamente diseñados y comercializados para niños de diferentes grupos de edad (13-17); información ausente o reducida para la correcta utilización de los medicamen-tos; alto riesgo de errores y eventos relacionados con los medicamentos (11,12,14,17).…”