O processo de preparo e administração de medicamentos: identificação de problemas para propor melhorias e prevenir erros de medicação

Miasso, Adriana Inocenti; Silva, Ana Elisa Bauer de Camargo; Cassiani, Sílvia Helena De Bortoli; Grou, Cris Renata; Oliveira, Regina Célia de; Fakih, Flávio Trevisan

doi:10.1590/s0104-11692006000300008

Cited by 74 publications

(86 citation statements)

References 6 publications

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“…Miasso et al (2006) analyzed the medication preparation and administration process in medical units at four Brazilian hospitals. Among the problems identified as contributing to the occurrence of medication errors, wrong drug-preparation errors and wrong administration-technique errors were observed in all hospitals.…”

Section: Resultsmentioning

confidence: 99%

Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

Dalmolin

Rotta

Goldim

2013

Braz. J. Pharm. Sci.

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Medication errors can be frequent in hospitals; these errors are multidisciplinary and occur at various stages of the drug therapy. The present study evaluated the seriousness, the type and the drugs involved in medication errors reported at the Hospital de Clínicas de Porto Alegre. We analyzed written error reports for 2010-2011. The sample consisted of 165 reports. The errors identified were classified according to seriousness, type and pharmacological class. 114 reports were categorized as actual errors (medication errors) and 51 reports were categorized as potential errors. There were more medication error reports in 2011 compared to 2010, but there was no significant change in the seriousness of the reports. The most common type of error was prescribing error (48.25%). Errors that occurred during the process of drug therapy sometimes generated additional medication errors. In 114 reports of medication errors identified, 122 drugs were cited. The reflection on medication errors, the possibility of harm resulting from these errors, and the methods for error identification and evaluation should include a broad perspective of the aspects involved in the occurrence of errors. Patient safety depends on the process of communication involving errors, on the proper recording of information, and on the monitoring itself.Uniterms: Medication/errors. Drug therapy. Patients/safety. Erros envolvendo medicamentos ocorrem frequentemente em hospitais, possuem natureza multidisciplinar e podem ocorrer nas várias etapas da terapia medicamentosa. O estudo avaliou a seriedade, o tipo e os medicamentos envolvidos nos erros de medicação notificados no Hospital de Clínicas de Porto Alegre. Foram analisadas notificações de erros realizadas por escrito em 2010-2011. A amostra foi composta por 165 notificações. Cento e catorze notificações foram classificadas como erros de fato (erros de medicação) e 51 notificações, como erros potenciais. Apesar de se ter realizado maior número de notificações de erros de medicação em 2011, comparativamente a 2010, não houve alteração significativa no perfil de seriedade destes eventos. O tipo de erro mais frequente foi o de prescrição (48,25%). Os erros ocorridos ao longo do processo geraram, em algumas situações, novos erros de medicação associados. Nas 114 notificações de erros de medicação identificadas citaram-se 122 medicamentos. A reflexão sobre os erros de medicação e a possibilidade de danos decorrentes dos mesmos, assim como dos métodos para a sua identificação e avaliação, deve incluir uma ampla perspectiva dos aspectos envolvidos na sua ocorrência. A segurança dos pacientes depende deste processo de comunicação, do registro adequado das informações e do monitoramento propriamente dito.

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Section: Resultsmentioning

confidence: 99%

Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

Dalmolin

Rotta

Goldim

2013

Braz. J. Pharm. Sci.

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Section: Introductionmentioning

confidence: 99%

“…The rate of errors is considered one of the best indicators of quality of medication distribution systems and is still used to evaluate the safety of these systems (4,6,9) .…”

Section: Introductionmentioning

confidence: 99%

“…

The rate of errors is considered one of the best indicators of quality of medication distribution systems and is still used to evaluate the safety of these systems (4,6,9) .

Some studies, published in the United States and England, showed an incidence of dispensing errors of about 10%, even in hospitals with advanced medication distribution systems, such as unit doses (7,11) .

A few studies were carried out in Brazil, specifically on medication dispensing processes, and presented high rates of errors, above 10% (5,8) .

…”

mentioning

confidence: 99%

“…Literature suggests that the incidence of medication errors in pediatrics is twice or three times as high as in adults, and also that pediatric patients are at higher risk of death when compared to adults (7)(8)(9)(10)(11) . These errors also represent an important The pharmacy service is responsible for the safe and efficient use of medication in hospitals and plays an essential role in integrating the prescription, dispensing and administration processes and should have policies and procedures to prevent errors (4)(5)8) .…”

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Medication dispensing errors at a public pediatric hospital

Costa

Valli

Alvarenga³

2008

Rev. Latino-Am. Enfermagem

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(4)(5)(6) .Literature suggests that the incidence of medication errors in pediatrics is twice or three times as high as in adults, and also that pediatric patients are at higher risk of death when compared to adults (7)(8)(9)(10)(11) . These errors also represent an important The pharmacy service is responsible for the safe and efficient use of medication in hospitals and plays an essential role in integrating the prescription, dispensing and administration processes and should have policies and procedures to prevent errors (4)(5)8) .The rate of errors is considered one of the best indicators of quality of medication distribution systems and is still used to evaluate the safety of these systems (4,6,9) .Some studies, published in the United States and England, showed an incidence of dispensing errors of about 10%, even in hospitals with advanced medication distribution systems, such as unit doses (7,11) .A few studies were carried out in Brazil, specifically on medication dispensing processes, and presented high rates of errors, above 10% (5,8) . In the pediatric area, especially in Brazil, no study was found on dispensing errors and, to date, their cause and epidemiology are unknown.Therefore, this study aims to evaluate the dispensing process of the pharmacy service at a public pediatric hospital. Important indicators were used to measure the dispensing process and the rate of total dispensing errors was the global indicator of its quality. MATERIAL AND METHODS Study designCross-sectional, descriptive study, carried out Variables OperationalizationErrors were classified according to the criteria used in a previous study (10) in:Content errors

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Incidentes críticos relacionados aos eventos adversos a medicamentos em uma unidade de clínica médica de um hospital público do Estado do Amazonas

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A Deus Pai, Senhor e Criador de todas as coisas, por sua presença constante em todos os momentos da minha vida e conceder-me a graça de alcançar meus objetivos ao lado de minha família.Aos meus pais Francisco Luiz da Silva (in memorian) e Iêda Soares da Silva, pelo amor, carinho, disciplina e coragem para educar meus irmãos.À minha querida e amada esposa, razão maior das minhas conquistas, companheira e amiga de todas as horas, mãe dedicada e amorosa com minhas filhas Emanuelle Caroline, Sophia Gabrielle e meu filho Luigi Brunno querido e esperado por todos. A você meu amor, meu carinho, minha admiração e meu respeito.Aos meus queridos irmãos e irmãs: Ivonnea (in memorian), Ivanda, Ivanete, Ivaneide, Iêda, Ivanilce, Maurílio, Irlêda e Moisés, meu amor e meu respeito por todos vocês é eterno.Ao meu sogro Sr. Edson e minha sogra Sra. Sandra, meu carinho e minha gratidão por tudo, obrigado por tanta demonstração de amor e carinho a minha família. AGRADECIMENTOSÀ minha querida orientadora, Profa. Dra. Silvia Helena De Bortoli Cassiani, por sua postura profissional, por sua sabedoria, por sua exigência metodológica, por seu rigor científico, por seus ensinamentos, por confiar em mim e estimular o crescimento pessoal e profissional.

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O processo de preparo e administração de medicamentos: identificação de problemas para propor melhorias e prevenir erros de medicação

Cited by 74 publications

References 6 publications

Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

Medication dispensing errors at a public pediatric hospital

Incidentes críticos relacionados aos eventos adversos a medicamentos em uma unidade de clínica médica de um hospital público do Estado do Amazonas

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