Ana Elisa Bauer de Camargo Silva

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.

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.

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.

Quality of nursing care and satisfaction of patients attended at a teaching hospital.

OBJETIVOS: evaluar la calidad de los cuidados de enfermeria, la satisfaccion del paciente y la correlacion entre ambos. METODO: estudio trasversal con 275 pacientes internados en un hospital de ensenanza de la region Centro-Oeste de Brasil. Los datos fueron recolectados mediante la aplicacion simultanea de tres instrumentos. A seguir, fueron digitalizados en un banco de datos electronico y analizados en funcion de la positividad, valor de mediana y coeficientes de correlacion de Spearman. RESULTADOS: entre los cuidados de enfermeria evaluados, solamente dos fueron considerados seguros - higiene y comfort fisico; nutricion e hidratacion - y los demas clasificados como pobres. Sin embargo, los pacientes se mostraron satisfechos con los cuidados recibidos en los dominios evaluados: tecnico-profesional, confianza y educacional. Eso puede ser justificado por la correlacion debil a moderada observada entre esas variables. CONCLUSION: A pesar del deficit de calidad, fue encontrado alto nivel de satisfaccion de los pacientes con los cuidados de enfermeria recibidos. Tales resultados indican la necesidad de que la institucion centre sus objetivos en un sistema de evaluacion permanente de la cualidad del cuidado, buscando atender a las expectativas de los pacientes

Erros de medicação em hospital universitário: tipo, causas, sugestões e providências

Este estudo survey exploratorio analisou os erros de medicacao de um hospital universitario a partir de 40 entrevistas realizadas com profissionais do sistema de medicacao. Os resultados mostraram que os tipos de erros mais frequentes estao na prescricao de medicamentos (29,04%); as falhas individuais sao consideradas as principais causa da ocorrencia de erros (47,37%) e as principais falhas do sistema de medicacao (26,98%); as alteracoes nas atitudes individuais sao sugestoes para evitar erros (28,26%); as orientacoes sao as providencias administrativas mais utilizadas (25%). Concluiu-se que nao ha consciencia sistemica entre os profissionais a respeito dos erros, focando a culpa no ser humano. E necessario que esta cultura seja alterada e transformada em melhorias para o sistema.This exploratory study (survey) has analyzed the errors of medication in a university hospital on the basis of 40 interviews conducted with professionals of the medication system. The results showed that the most frequent types of errors occur in drug prescription (29.04%); individual flaws are considered the main cause of errors (47.37%) and the main flaws in the medication system (26.98%); changes in individual attitudes are suggested as a way to avoid errors (28.26%); guidance is the most utilized administrative action (25%). The conclusion is that there is no systemic awareness among professionals regarding errors, putting the blame on the human being. This culture must be altered and transformed into improvements for the system.

Errors in medicine administration - profile of medicines: knowing and preventing

Objectives: To describe the pharmacological characteristics of medicines involved in administration errors and determine the frequency of errors with potentially dangerous medicines and low therapeutic index, in clinical units of five teaching hospitals, in Brazil. Methods: Multicentric study, descriptive and exploratory, using the non-participant observation technique (during the administration of 4958 doses of medicines) and the anatomical therapeutic chemical classification (ATC). Results: Of that total, 1500 administration errors were identified (30.3%). The administration of pharmacological groups - ATC (cardiovascular system, nervous system, alimentary tract and metabolism system and anti-infectives for systemic use) showed a higher frequency of errors. In 13.0% of errors were involved potentially dangerous medicines and in 12.2% medicines with low therapeutic index. Conclusion: The knowledge of the pharmacological profile could be an important strategy to be used in the prevention medication errors in health institutions.OBJETIVOS: Descrever as caracteristicas farmacologicas dos medicamentos envolvidos em erros de administracao e determinar a frequencia desses erros com medicamentos potencialmente perigosos e de baixo indice terapeutico em unidades de clinica medica de cinco hospitais de ensino brasileiros. METODOS: Estudo multicentrico, descritivo/exploratorio utilizando a tecnica de observacao nao participante durante a administracao de 4958 doses de medicamentos e a classificacao anatomica terapeutica quimica (ATC). RESULTADOS: Dentre esse total, foram identificados 1500 erros de administracao de medicamentos (30,3%). A administracao dos farmacos dos grupos ATC - sistema cardiovascular, sistema nervoso, trato alimentar e metabolismo e antinfecciosos de uso sistemico apresentou maior frequencia de erros. Em 13,0% dos erros estavam envolvidos medicamentos potencialmente perigosos e em 12,2% medicamentos de baixo indice terapeutico. CONCLUSAO: O conhecimento do perfil farmacologico pode ser uma importante estrategia a ser utilizada na prevencao de erros de medicacao em instituicoes de saude.