Edson Perini

Erros de medicação: quem foi?

New diagnostic and therapeutic technologies are used with growing frequency, improving the quality of medical assistance and increasing life expectancy. Health care, however, is becoming progressively more expensive and complex. Adverse events related to medical assistance, particularly errors, are becoming public, being debated and judged in courts. Given their training, health workers are not prepared to deal with errors, which are associated with shame, fear and punishment. The approach to errors in the health system is usually individualistic, considering such events as acts of insecurity performed by careless, non-motivated and ill-trained persons. The tendency is to hide errors when they occur, with the result that an important learning opportunity is lost. There is another way to deal with errors, a systemic view that has obtained positive results in sectors such as aviation, anesthesiology and unit-dose drug distribution systems. These systems have varied degrees of safety and should take into account human limitations when designed and applied. A change in paradigm is needed when dealing with drugs, as it is not enough for a drug to have quality assurance, but the complete process of drug use should be safe. Medication errors, avoidable by definition, are at present a serious public health issue, leading to loss of lives and significant financial losses. A systemic approach to medication errors may disclose failures in the process as a whole, and improvements can be implemented to reduce their occurrence.

Erros na prescrição hospitalar de medicamentos potencialmente perigosos

OBJETIVO:Los errores de medicacion son actualmente un problema mundial de salud publica, siendo los mas serios los de prescripcion. El objetivo del estudio fue analizar la practica de la prescripcion de medicamentos de alto riesgo y su relacion con la prevalencia de errores de medicacion en ambiente hospitalario. METODOS: Estudio transversal retrospectivo abarcando 4.026 prescripciones con medicamentos potencialmente peligrosos. Durante 30 dias de 2001, fueron analizadas todas las prescripciones recibidas en la farmacia de un hospital de referencia del estado de Minas Gerais (Sureste de Brasil). Las prescripciones fueron analizadas con relacion a: legibilidad, nombre del paciente, tipo de prescripcion, fecha, caligrafia o grafia, identificacion del prescriptor, analisis del medicamento y uso de abreviaturas. Los errores de prescripcion fueron clasificados como de redaccion o decision, siendo evaluada la influencia del tipo de prescripcion en la ocurrencia de errores. RESULTADOS: Hubo predominio de la prescripcion escrita a mano (45,7%). En 47,0% de las prescripciones escritas a mano, mixtas y pre-digitadas ocurrieron errores en el nombre del paciente, en 33,7% hubo dificultades en la identificacion del prescriptor y 19,3% estaban poco legibles o ilegibles. En un total de 7.148 medicamentos de alto riesgo prescritos, fueron observados 3.177 errores, siendo mas frecuente la omision de informacion (86,5%). Los errores se concentraron principalmente en los medicamentos heparina, fentanil y midazolam; y los sectores de tratamiento intensivo y la neurologia presentaron mayor numero de errores por prescripcion. Se observo el uso intensivo y sin estandarizacion de abreviaturas. Cuando se computaron todos los tipos de errores, se verifico 3,3 por prescripcion. La prescripcion pre-digitada presento menor probabilidad de errores en comparacion con las mixtas o escritas a mano. CONCLUSIONES:Los resultados sugieren la necesidad de la estandarizacion en el proceso de prescripcion y la eliminacion de aquellas hechas a mano. El uso de prescripciones pre-digitadas o editadas podra disminuir los errores relacionados a los medicamentos potencialmente peligrosos.OBJECTIVE Medication errors are currently a worldwide public health issue and it is one of the most serious prescription errors. The objective of the study was to evaluate the practice of prescribing high-alert medications and its association with the prevalence of medication errors in hospital settings. METHODS A retrospective cross-sectional study was conducted including 4,026 prescription order forms of high-alert medications. There were evaluated all prescriptions received at the pharmacy of a reference hospital in the state of Minas Gerais, southeastern Brazil, over a 30-day period in 2001. Prescription were checked for legibility, patient name, type of prescription, date, handwriting or writing, prescriber identification, drug prescribed, and use of abbreviations. Prescription errors were classified as writing or decision errors and how the type of prescription affected the occurrence of errors was assessed. RESULTS Most prescriptions were handwritten (45.7%). In 47.0% of handwritten, mixed and pre-typed prescriptions had patient name errors; the prescriber name was difficult to identify in 33.7%; 19.3% of them were hardly legible or illegible. Of a total of 7,148 high-alert drugs prescribed, 3,177 errors were found, and the most frequent one was missing information (86.5%). Errors occurred mostly in prescriptions of heparin, phentanyl, and midazolam. Intensive care and neurology units had the highest number of errors per prescription. Non-standard abbreviations were frequent and widespread. Overall it was estimated 3.3 errors per prescription order form. Pre-typed prescriptions were less likely to have errors compared to mixed or handwritten prescriptions. CONCLUSIONS The study results show there is a need for standardizing the prescription process and eliminating handwritten prescriptions. The use of pre-typed or edited prescriptions may reduce errors associated to high-alert medications.

Medication errors and drug-dispensing systems in a hospital pharmacy

Pharmacies permeate and interconnect various actions developed in different sectors within the complex process of the use of drugs in a hospital. Dispensing failures mean that a breach has occurred in one of the last safety links in the use of drugs. Although most failures do not harm patients, their existence suggests fragility in the process and indicates an increased risk of severe accidents. Present concepts on drug-related incidents may be classified as side effects, adverse effects, and medication errors. Among these are dispensing errors, usually associated with poor safety and inefficient dispensing systems. Factors associated with dispensing errors may be communication failures, problems related to package labels, work overload, the physical structure of the working environment, distraction and interruption, the use of incorrect and outdated information sources and the lack of patient knowledge and education about the drugs they use. So called banal dispensing errors reach significant epidemiological levels. The purpose of this paper, which is part of a study on the occurrence of dispensing errors in the pharmacy of a large hospital, is to review the main concepts that guide studies on adverse effects and to provide an update on dispensing errors.

Drug-dispensing errors in the hospital pharmacy

OBJECTIVE To determine the dispensing error rate and to identify factors associated with them, and to propose prevention actions. METHODS A cross-sectional study focusing on the occurrence of dispensing errors in a general hospital in Belo Horizonte that uses a mixed system (a combination of multidose and unit dose systems) of collective and individualized dosing. RESULTS A total of 422 prescription order forms were analyzed, registering 81.8% with at least 1 dispensing error. Opportunities for errors were higher in the pretyped prescription order forms (odds ratio = 4.5; P <.001), in those with 9 or more drugs (odds ratio = 4.0; P <.001), and with those for injectable drugs (odds ratio = 5.0; P <.001). One of the teams of professionals had a higher chance of errors (odds ratio = 2.0; P =.02). A multivariate analysis ratified these results. CONCLUSIONS The dispensing system at the pharmacy can produce many latent failures and does not have an adequate control; it has several conditions that predispose it to the occurrence of errors, contributing to the high rate reported.OBJETIVO: Determinar a taxa de erros de dispensacao e identificar fatores associados, propondo acoes de prevencao. METODOS: Estudo transversal investigou-se a ocorrencia de erros de dispensacao em um hospital geral de Belo Horizonte que emprega um sistema misto de dose coletiva e individualizada. RESULTADOS: Foram analisadas 422 prescricoes, registrando em 81,8% destas pelo menos um erro de dispensacao. Oportunidades de erros foram maiores nas prescricoes pre-digitadas (Odds Ratio=4,5; p<0,001), naquelas com nove ou mais medicamentos (Odds Ratio=4,0; p<0,001) e com os injetaveis (Odds Ratio=5,0; p<0,001). Uma das equipes de profissionais apresentou maior chance de erros (Odds Ratio=2,0; p=0,02). A analise multivariada ratifica estes resultados. CONCLUSAO: Conclui-se que o sistema de dispensacao da farmacia apresenta muitas falhas latentes e poucas defesas, com diversas condicoes que predispoe a ocorrencia de erros, contribuindo para a elevada taxa registrada.

Analysis of medical prescriptions dispensed at health centers in Belo Horizonte, Minas Gerais, Brazil

This article focuses on medical prescriptions dispensed at health centers under the Municipal Health Department in Belo Horizonte, Minas Gerais State, Brazil. The study analyzed 4,607 prescriptions from March to April 1999, grouped according to origin (internal or external). The analysis focused on information written on medical prescriptions. The main findings were: (a) an average of 2.4 drugs per prescription in both groups; (b) prescriptions filled out with 4 or more drugs accounted for 18.0% of internal and 17.6% of external prescriptions; (c) 84.3% of internal and 85.5% of external prescriptions provided no instructions for use of medication; (d) information on dosage regimen varied from 51.2% to 97.6% for internal and 57.9% to 96.5% for external prescriptions; (e) generic names were specified for 51.9% and 28.4% of all drugs on internal and external prescriptions, respectively; (f) prescriptions containing standard drugs from the Municipal Health Department accounted for 88.7% of internal and 76.4% of external prescriptions. Data analysis shows the need for continuing education of physicians and adoption of other methods to improve quality of prescriptions and promote rational use of drugs.

Prescrição de medicamentos de uso sistêmico por cirurgiões-dentistas, clínicos gerais

OBJETIVO: Estudar o padrao de prescricao de medicacao antimicrobiana e analgesica/ antiinflamatoria de uso sistemico na clinica odontologica. METODOS: Estudo observacional realizado a partir de questionarios respondidos por uma amostra representativa randomica de 163 cirurgioes-dentistas, clinicos gerais, da Regiao Metropolitana de Belo Horizonte. Alguns dos aspectos verificados foram a prevalencia de prescricoes dessas medicacoes nas duas semanas anteriores a aplicacao do questionario; uso do nome generico nas receitas odontologicas; realizacao de cursos de reciclagem em farmacologia; auto-avaliacao sobre o grau de conhecimento e importância dada a esta disciplina para a pratica profissional e preenchimento de fichas clinicas e registro nestas das prescricoes realizadas. RESULTADOS E CONCLUSOES: Observou-se que os medicamentos sao prescritos pelo nome comercial, com tendencia a prescrever mais frequentemente antiinflamatorios em relacao aos analgesicos. Uma percentagem de 13% de individuos nao realiza ficha clinica para todos os seus pacientes e cerca de 43% da amostra nao registra suas prescricoes. Os cursos de reciclagem em farmacologia parecem nao alterar a auto-avaliacao sobre o nivel de conhecimento em farmacologia e o uso do nome generico.OBJECTIVE The study of the prescription pattern of antibacterial and analgesic/antiinflammatory systemic medication by dentists. METHODS Observational study based in questionnaires answered by a representative, randomly selected sample of 163 general dentists from the Metropolitan Region of Belo Horizonte, Southeastern Brazil. Some of the topics verified were: the most frequently prescribed drugs in the fortnight prior to the study, the use of generic names of drugs in the prescriptions, attendance at refresher courses on pharmacology, self-assessment of degree of knowledge on pharmacology, the importance given to this subject in the dentists professional career, and the filling out of the clinical chart and the registration of the drugs prescribed on it. RESULTS It was observed that the drugs were usually prescribed by their commercial name. There were a trend to prescribe more antiinflamatory than analgesics drugs. A small, but worrying, 13% of dentists didnot fill out the clinical chart for all the patients and 43% of the sample didnot register the drugs prescribed on it. The courses on pharmacology seemed to produce no significant alteration in self valuation as to the degree of knowledge in pharmacology and the use of the generic names of drugs.

Desabastecimento de medicamentos: determinantes, conseqüências e gerenciamento

The present study analyzes drug shortage as a problem reaching beyond the logistic aspect of the health field and discusses its consequences with respect to quality, safety and cost of health care delivery. The pharmaceutical supply chain and the factors that determine the distribution and availability of drugs are discussed. The contribution of the Pharmacy and Therapeutics Committee in preventing and managing drug shortage in health institutions is stressed and measures for drug shortage management are suggested. Finally it is emphasized that drugs should be considered health products rather than consumer goods and as such be given a different treatment by the supply chain.

Heparin-induced thrombocytopenia: a review of concepts regarding a dangerous adverse drug reaction

Heparin is a natural agent with antithrombotic action, commercially available for therapeutic use as unfractionated heparin and low molecular weight heparin. Heparin-induced thrombocytopenia (HIT) is a serious adverse reaction to heparin that promotes antibody-mediated platelet activation. HIT is defined as a relative reduction in platelet count of 50% (even when the platelet count at its lowest level is above>150 x 10(9)/L) occurring within five to 14 days after initiation of the therapy. Thrombocytopenia is the main feature that directs the clinical suspicion of the reaction and the increased risk of thromboembolic complications is the most important and paradoxical consequence. The diagnosis is a delicate issue, and requires a combination of clinical probability and laboratory tests for the detection of platelet activation induced by HIT antibodies. The absolute risk of HIT has been estimated between 1% and 5% under treatment with unfractionated heparin, and less than 1% with low molecular weight heparin. However, high-quality evidence about the risk of HIT from randomized clinical trials is scarce. In addition, information on the frequency of HIT in developing countries is not widely available. This review aims to provide a better understanding of the key features of this reaction and updated information on its frequency to health professionals and other interested parties. Knowledge, familiarity, and access to therapeutic options for the treatment of this adverse reaction are mandatory to minimize the associated risks, improving patient safety.

Historical evolution of package inserts in Brazil

In Brazil, package inserts provide key information on pharmaceuticals. The current study analyzes the evolution of package inserts and the impact on this process by scientific research and development, globalization of information, and various health policies. The study began with a retrospective review of Brazilian health legislation until 1920, the year when the National Public Health Department was created. The analysis of documents on the evolution of health regulation in Brazil began with the Brazilian Pharmaceutical Collection-Health Rulings. The second stage of the study involved a search of standards and norms in VISALEGIS: Health Surveillance Legislation, Portal for Legislation from the National Congressional Information System and the Health Legislation System. Package inserts became an important vehicle for information in the country and underwent important regulatory changes in the latter half of the 20th century. From 1946 to 2006, the number of mandatory items increased, with more in-depth description. However, the standardization of information for medicines with the same active ingredient failed to materialize, despite its importance and the various legal initiatives in this direction.

Fatores associados ao uso de benzodiazepínicos no serviço municipal de saúde da cidade de Coronel Fabriciano, Minas Gerais, Brasil

Numerous countries have witnessed increasing misuse of benzodiazepines. This cross-sectional study assessed the factors associated with prescription of benzodiazepines for users of the Municipal Health Service in Colonel Fabriciano, Minas Gerais State, Brazil. Data were collected from official records on drug prescription (n = 1,866) from September to October 2006. Bivariate and multivariate analyses using Poisson regression were performed. Prolonged benzodiazepine use was independently associated with benzodiazepine type and patient participation in health programs. Concomitant use of other psychoactive drugs was independently associated with age and participation in health programs. Type of benzodiazepine (clonazepam or diazepam) was independently associated with age and gender, as well as with participation in health programs. Factors associated with benzodiazepine prescription show the problems extent and should be considered in planning interventions to rationalize the use of these drugs in Brazil, particularly through health program planning.