Adriana Inocenti Miasso

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

Este estudo exploratorio analisou o processo do preparo e administracao de medicamentos de unidades de clinica medica de quatro hospitais brasileiros, localizados nas Regioes Sudeste, Centro-oeste e Nordeste do Brasil. Identificou os problemas que podem contribuir para a ocorrencia de erros de medicacao e propos medidas de melhorias. Os dados foram coletados atraves de observacao nao-participante e direta das atividades dos profissionais de enfermagem por uma semana. Os resultados revelaram como principais problemas o ambiente no Hospital B, falhas no preparo relacionadas a tecnica e ao preparo antecipado dos medicamentos no C e D, falhas de tecnica, comunicacao e identificacao do paciente no A. A formacao de uma comissao multidisciplinar para avaliar o sistema, grupos de discussao entre a enfermagem, melhorias do ambiente, cursos e treinamento continuos e presenca efetiva da enfermeira no processo sao algumas sugestoes para maior qualidade e seguranca na assistencia aos pacientes.

Problemas na comunicação: uma possível causa de erros de medicação

OBJECTIVE: This descriptive study identified and analyzed weak points in the communication process during the prescription, dispensing, and administration of medication in a medical unit and pharmacy of a university hospital. METHODS: The data were collected by direct observations during a period of 21 days, review of 294 prescriptions, and interview of 40 health care professionals. RESULTS: Some prescriptions were incomplete, common use of abbreviations, and health care providers were often interrupted or distracted during prescription. During the dispensing phase, many requisition forms were incomplete or filled out wrongly. And, during the administration of medication, there were errors on transcribed labels for the preparation of medication as well as a lack of proper communication between nurses and patients. CONCLUSION: Communication process in place must be revised to guarantee a quality hospital medication system that provides safe patient care.OBJECTIVE: This descriptive study identified and analyzed weak points in the communication process during the prescription, dispensing, and administration of medication in a medical unit and pharmacy of a university hospital. METHODS: The data were collected by direct observations during a period of 21 days, review of 294 prescriptions, and interview of 40 health care professionals. RESULTS: Some prescriptions were incomplete, common use of abbreviations, and health care providers were often interrupted or distracted during prescription. During the dispensing phase, many requisition forms were incomplete or filled out wrongly. And, during the administration of medication, there were errors on transcribed labels for the preparation of medication as well as a lack of proper communication between nurses and patients. CONCLUSION: Communication process in place must be revised to guarantee a quality hospital medication system that provides safe patient care.

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

Este estudo analisou, em quatro hospitais brasileiros, tipos, causas, providencias administrativas tomadas e sugestoes, em relacao aos erros na medicacao, na perspectiva dos profissionais envol-vidos no sistema de medicacao. Trata-se de um estudo multicentrico, do tipo survey exploratorio. A amostra constou de profissionais de clinica medica e farmacia, dos referidos hospitais. Para coleta de dados, utilizou-se a tecnica de entrevista semi-estruturada. Os resultados evidenciaram que os tipos de erros mais citados pelos profissionais foram aqueles relacionados a prescricao/transcricao dos medicamentos. A falta de atencao, falhas individuais e problemas na administracao dos servicos constituiram importantes atributos das causas dos erros. Relatorios foram as prin-cipais providencias tomadas ante os erros e mudancas nas atitudes individuais as mais citadas como forma de preveni-los.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.

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

In Brazil, millions of prescriptions do not follow the legal requirements necessary to guarantee the correct dispensing and administration of medication. This multi-centre exploratory study aimed to analyze the appropriateness of prescriptions at four Brazilian hospitals and to identify possible errors caused by inadequacies. The sample consisted of 864 prescriptions obtained at hospital medical clinics in January 2003. Data was collected by three nurse researchers during one week using a standard data sheet that included items about: the type of prescription; legibility; completeness; use of abbreviations; existence of changes and erasures. There were statistically significant differences between incomplete electronic prescriptions at hospital A, and handwritten ones from hospitals C (C2 = 12.703 and p < 0.001) and D (C2 = 14.074 and p < 0.001). Abbreviations were used in more than 80% of prescriptions at hospitals B, C and D. Changes were found in prescriptions at all hospitals, with higher levels at hospitals B (35.2%) and A (25.3%). This study identified a range of vulnerable points in the prescription phase of the medication system at the hospitals. Physicians, pharmacists and nurses should therefore jointly propose strategies to avoid these prescription errors.

Erros mais comuns e fatores de risco na administração de medicamentos em unidades básicas de saúde

Este estudo identificou e analisou as opinioes de enfermeiros e profissionais de enfermagem sobre os fatores de risco mais comuns a ocorrencia dos erros na administracao de medicamentos, as consequencias, intervencoes tomadas e medidas que minimizariam essa ocorrencia. Para tanto, aplicou-se um instrumento para coleta de dados contendo questoes sobre as opinioes de profissionais de enfermagem, atuantes em Unidades Basicas de Saude de uma cidade do interior paulista. Os resultados indicaram que os fatores de risco associados ao proprio profissional foram a falta de atencao e dificuldade de entender prescricoes medicas. As intervencoes tomadas estao relacionadas a punicao e educacao e as propostas para minimizar as ocorrencias dos erros foram a orientacao e reciclagem dos profissionais envolvidos.The present study identified and analyzed the opinions of nurses and nursing professionals about the more common risk factors regarding errors in medicine administration as well as the consequences, interventions and measures to minimize this problem. Therefore, the authors applied an instrument of data collection with questions on the opinions of the nursing professionals who work at the Basic Health Units from a city of the state of Sao Paulo. Results showed that the risk factors associated to the professional were lack of attention and difficulty to understand medical prescriptions. The interventions were related to punishment and education and the proposals to minimize the occurrences were orientation and up-date of the involved professionals.

Sentimentos de profissionais de enfermagem após a ocorrência de erros de medicação

Objective: To understand the feelings of nursing professionals who have committed medication errors. Methods: Descriptive and exploratory study with a qualitative approach. The subjects were 15 nursing professionals from a university hospital in Goiânia. Data were collected by interviews guided by a semi-structured instrument, which were recorded and analyzed according to the premises of Bardin. Results: The results showed that the most common feelings are panic, despair, fear, guilt and shame, among others. The coping strategies they adopt include looking for someone to share the problem, formally communicating the error and looking for information and knowledge. Conclusion: Hospitals should not ignore that human beings can err, but turn this into a motive to implement systemic strategies, such as the review of medication processes, ideal work conditions, psychological support and investment in continuing education.Objective: To understand the feelings of nursing professionals who have committed medication errors. Methods: Descriptive and exploratory study with a qualitative approach. The subjects were 15 nursing professionals from a university hospital in Goiânia. Data were collected by interviews guided by a semi-structured instrument, which were recorded and analyzed according to the premises of Bardin. Results: The results showed that the most common feelings are panic, despair, fear, guilt and shame, among others. The coping strategies they adopt include looking for someone to share the problem, formally communicating the error and looking for information and knowledge. Conclusion: Hospitals should not ignore that human beings can err, but turn this into a motive to implement systemic strategies, such as the review of medication processes, ideal work conditions, psychological support and investment in continuing education.

Aspectos gerais e número de etapas do sistema de medicação de quatro hospitais brasileiros

This study identified and analyzed the medication systems in 04 university hospitals located in Recife, Ribeirão Preto, Goiânia and São Paulo, Brazil, after approval by the Research Ethics Committee and authorization by the hospital directors. Data were collected through a structured interview with one of the professionals in charge of the medication system and non-participant and direct observation during one week. The results indicated the points requiring improvement, such as the use of abbreviations, lack of standardization in medication administration times, lack of updated and complete information about the patient, the pharmacys not working 24 hours a day in hospitals and others. 66 phases were shown in Hospital A, 58 in B, 70 in C, and 80 in D concerning the medication system. Simplifying the processes by reducing the number of phases is the key to reducing medication errors.Essa investigacao identificou e analisou o sistema de medicacao de 04 hospitais universitarios, localizados nas cidades de Recife, Ribeirao Preto, Goiânia e Sao Paulo, apos a aprovacao nos Comites de Etica em Pesquisa e da autorizacao da direcao dos hospitais. Os dados foram coletados atraves de entrevista estruturada com um dos profissionais responsaveis pelo sistema de medicacao e observacao nao participante e direta, por uma semana, nos varios sub-sistemas. Os resultados indicaram pontos que necessitam de aperfeicoamentos como utilizacao de abreviacoes, falta de padronizacao de horarios de administracao de medicamentos, falta de informacoes atualizadas e completas do paciente, farmacia nao funcionando 24 horas em um hospital, falta de centro de informacoes de medicamentos e outros. Evidenciou-se no hospital A 66 etapas, no B 58 etapas, no C 70 etapas e no D 80 etapas do sistema de medicacao. Simplificar os processos, diminuindo o numero de etapas, e a chave para a reducao de erros de medicacao.

Administração de medicamentos: orientação final de enfermagem para a alta hospitalar

Este estudio evaluo la orientacion final de enfermeria para el alta hospitalaria en cuanto a la terapeutica medicamentosa en una clinica de internamiento hospitalario. La muestra consto de 38 pacientes con alta hospitalaria en diciembre del 2001, febrero del 2002 y de los enfermeros que los orientaron. Para la recoleccion de los datos se utilizo la tecnica de observacion no-participante. Obtuvimos como resultados: locales inadecuados para la orientacion, pocas informaciones por escrito, corto tiempo para la orientacion y no utilizacion de estrategias que confirmen el entendimiento del paciente en cuanto a las orientaciones. Se concluyo que tales aspectos pueden estar contribuyendo para la ocurrencia de errores de medicacion en el domicilio, despues del alta hospitalaria.This study assessed the final nursing orientation for hospital release in what refers to the medicamental therapeutics in a clinic of hospital internment. The sample was comprised of 38 patients that had hospital release in December of 2001, February of 2002 and of the nurses who oriented them. The technique used for collecting data was non-participant observation. The results obtained were: inadequate places for orientation, few written information, short time for orientation and no use of strategies that confirm the comprehension of the orientation on the part of the patient. The conclusion is that those problems may be contributing for the occurrence of errors in the use of medicines at home, after hospital release.

Medication preparation and administration: analysis of inquiries and information by the nursing team

This study analyzed questions presented by nursing technicians and auxiliaries during medication preparation and administration. Data were collected through a form in which nurses who worked in the hospitalization unit of a general hospital in Sao Paulo, Brazil, were asked to take notes of any questions asked to them. Most of the 255 questions were related to medication dilution (103). Regarding the answers source, only 7.5% of answers were obtained from pharmaceutical professionals, 35.5% of the answers given by nurses was incorrect or partially correct, which can constitute a factor for medication administration errors. In addition, there are no pharmacists present in hospitalization units of Brazilian hospitals. These professionals could, jointly with nurses, facilitate medication orientation to nursing professionals during preparation and administration, as well as to patients themselves.This study analyzed questions presented by nursing technicians and auxiliaries during medication preparation and administration. Data were collected through a form in which nurses who worked in the hospitalization unit of a general hospital in São Paulo, Brazil, were asked to take notes of any questions asked to them. Most of the 255 questions were related to medication dilution (103). Regarding the answers source, only 7.5% of answers were obtained from pharmaceutical professionals, 35.5% of the answers given by nurses was incorrect or partially correct, which can constitute a factor for medication administration errors. In addition, there are no pharmacists present in hospitalization units of Brazilian hospitals. These professionals could, jointly with nurses, facilitate medication orientation to nursing professionals during preparation and administration, as well as to patients themselves.

Adverse drug events in a sentinel hospital in the State of Goiás, Brazil

This was a retrospective, descriptive and documental study with the aim of identifying adverse drug events which occurred in the medication administration process and to classify these medication errors. This study was developed in the internal medicine unit of a general hospital of Goiás, Brazil. Report books used by nursing staff from the period 2002 to 2007, were analyzed. A total of 230 medication errors were identified, most of which occurred in the preparation and administration of the medications (64.3%). Medication errors were of omission (50.9%), of dose (16.5%), of schedule (13.5%) and of administration technique (12.2%) and were more frequent with antineoplastic and immunomodulating agents (24.3%) and anti-infective agents (20.9%). It was found that 37.4% of drugs were high alert medications. Considering the medication errors detected it is important to promote a culture of safety in the hospital.Trata-se de estudo retrospectivo, documental e descritivo que teve como objetivo identificar os eventos adversos a medicamentos, ocorridos no processo administracao de medicamentos, e classificar os erros de medicacao. Este estudo foi desenvolvido na unidade de clinica medica de um hospital geral de Goias, Brasil. Foram analisados os livros utilizados pela equipe de enfermagem, no periodo de 2002 a 2007, para registros de passagem de plantao. Identificaram-se 230 erros de medicacao, sendo a maioria no preparo e administracao de medicamentos (64,3%). Os erros de medicacao foram de omissao (50,9%), de dose (16,5%), de horario (13,5%) e de tecnica de administracao (12,2%), sendo mais frequentes com antineoplasicos e imunomoduladores (24,3%) e anti-infecciosos (20,9%). Constatou-se que 37,4% dos medicamentos eram potencialmente perigosos. Considerando os erros de medicacao detectados, e importante promover cultura de seguranca no hospital.