Cris Renata Grou

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.

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.

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.

Preparo e administração de medicamentos: análise de questionamentos e informações da equipe de enfermagem

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.

Prescripción informatizada como factor contribuyente para la seguridad de los pacientes hospitalizados

www.pharmacypractice.org 13 RESUMEN * El presente estudio se realizó para identificar factores relacionados con los errores de medicación en las recetas informatizadas y sus ventajas y desventajas según los médicos, enfermeras y personal administrativo. Es un estudio descriptivo realizado en tres unidades de un hospital universitario del suroeste de Brasil. El estudio se dividió en dos fases. En la primera fase, analizamos un total de 1349 prescripciones de los servicios de medicina general, cirugía y ortopedia durante 30 días consecutivos. Se utilizó un instrumento semiestructurado, elaborado por un grupo de investigadores para este estudio. En la segunda fase, se aplicó un cuestionario semi-estructurado a los profesionales de la salud, que contenía preguntas abiertas y cerradas sobre sus opiniones sobre la prescripción electrónica, sus ventajas y desventajas, y sus sugerencias para mejorarla. De las 1349 prescripciones observadas, el 17,5% presentaban correcciones, el 25,0% estaba escrita manualmente y el 17,0% estaba incompleta. Algunas de las ventajas señaladas por los profesionales de la salud era su legibilidad (37,5%), poco tiempo empleado en elaborarla y emitirla (20,5%) y el modo práctico en que se organizaban (,0%). Las desventajas que se señalaban fueron la repetición de prescripciones previas (34,0%), los errores tipográficos (17,0%), la dependencia de los ordenadores (11,0%) y las alteraciones hechas manualmente (7,0%). En conclusión, la prescripción informatizada representa un gran progreso entre las estrategias utilizadas para minimizar los errores de medicación producidos por prescripciones mal formuladas. Sin embargo, no erradica la posibilidad la aparición de error, necesitándose algunas modificaciones.

The medication preparation and administration process: problem identification in order to propose improvements and prevent medication errors

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.

Preparación y administración de medicamentos: análisis de cuestionamientos e informaciones del equipo de enfermería

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.

El proceso de preparación y administración de medicamentos: identificación de problemas para proponer mejoras y prevenir errores de medicación

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.