Elena Bohomol

Medication errors in an intensive care unit

AIM This paper is a report of a study to investigating the incidence types and causes of medication errors (MEs) and the consequences for patients. Background. Medication errors are a common problem in hospitals around the world, including those in Brazil. METHOD An exploratory, quantitative survey design was used and 44 adult inpatients were studied over a 30-day period in 2006. Three different methods were employed: anonymous self-reports, staff interviews and review of patient prescriptions. FINDINGS A total of 305 MEs was observed. The mean (sd) number was 6.9 (6.8) per patient. The numbers of MEs per day differed statistically significantly between the two groups with length of stay in the intensive care unit of <1 week and more than 1 week, respectively, with mean (sd) of 0.4 (0.38) vs. 0.73 (0.39) The most frequent types were: omission (71.1%), wrong time of administration (11.5%), and prescribing errors (4.6%). The main causes were: medication not available in the hospital (41%); pharmacy stocking and delivery problems (16.3%); transcription errors (11%). No death was directly related to any ME. CONCLUSION There is a need to develop a culture of safety and quality in patient care. An understanding of the profile of ME types and frequencies in an institution is fundamental to raise awareness and implement measures to avoid them. Structural and procedural changes in hospital organization, with a focus on the efficacy, efficiency, and effectiveness of the medication system are needed to reduce MEs.

Erro de medicação: importância da notificação no gerenciamento da segurança do paciente

Notifying medication errors is an important instrument in managing assistance quality and safety for the patient. The objective of this study was to verify with the nursing team their understanding that a medication error had been committed, and to observe how they notified responsible physicians of the event. To achieve this, researchers used a descriptive/exploratory survey with 89 professionals. The results demonstrate a lack of uniformity in understanding that medication errors had been committed, when these errors must be communicated to a physician, and when an event report must be filled out. The research shows the necessity to develop educational programs that shed light on exactly what constitutes a medication error, clarifying causes of the problem and providing solutions to solve it.Notifying medication errors is an important instrument in managing assistance quality and safety for the patient. The objective of this study was to verify with the nursing team their understanding that a medication error had been committed, and to observe how they notified responsible physicians of the event. To achieve this, researchers used a descriptive/exploratory survey with 89 professionals. The results demonstrate a lack of uniformity in understanding that medication errors had been committed, when these errors must be communicated to a physician, and when an event report must be filled out. The research shows the necessity to develop educational programs that shed light on exactly what constitutes a medication error, clarifying causes of the problem and providing solutions to solve it.

Percepções sobre o erro de medicação: análise de respostas da equipe de enfermagem

Medication error is defined as any type of error in the prescription, transcription, dispensing and administration process which could bring about serious consequences or not. This descriptive and exploratory study assesses four scenarios showing situations from nursing practice. The study group was composed of 256 professionals and 89 questionnaires were analyzed. The answers given by the registered nurses were compared with those of licensed practical nurses and care aids. They should express their opinion if the situations represented a medication error or not, if it had to be communicated to the physician or an incident report had to be written. The two groups showed uniform answers. They expressed the same doubts to label the situation as an error and which measures should be taken, suggesting the need for further discussion on the matter within the institution.Medication error is defined as any type of error in the prescription, transcription, dispensing and administration process which could bring about serious consequences or not. This descriptive and exploratory study assesses four scenarios showing situations from nursing practice. The study group was composed of 256 professionals and 89 questionnaires were analyzed. The answers given by the registered nurses were compared with those of licensed practical nurses and care aids. They should express their opinion if the situations represented a medication error or not, if it had to be communicated to the physician or an incident report had to be written. The two groups showed uniform answers. They expressed the same doubts to label the situation as an error and which measures should be taken, suggesting the need for further discussion on the matter within the institution.

Perceptions about medication errors: analysis of answers by the nursing team

Medication error is defined as any type of error in the prescription, transcription, dispensing and administration process which could bring about serious consequences or not. This descriptive and exploratory study assesses four scenarios showing situations from nursing practice. The study group was composed of 256 professionals and 89 questionnaires were analyzed. The answers given by the registered nurses were compared with those of licensed practical nurses and care aids. They should express their opinion if the situations represented a medication error or not, if it had to be communicated to the physician or an incident report had to be written. The two groups showed uniform answers. They expressed the same doubts to label the situation as an error and which measures should be taken, suggesting the need for further discussion on the matter within the institution.Medication error is defined as any type of error in the prescription, transcription, dispensing and administration process which could bring about serious consequences or not. This descriptive and exploratory study assesses four scenarios showing situations from nursing practice. The study group was composed of 256 professionals and 89 questionnaires were analyzed. The answers given by the registered nurses were compared with those of licensed practical nurses and care aids. They should express their opinion if the situations represented a medication error or not, if it had to be communicated to the physician or an incident report had to be written. The two groups showed uniform answers. They expressed the same doubts to label the situation as an error and which measures should be taken, suggesting the need for further discussion on the matter within the institution.

Eventos adversos em pacientes cirúrgicos: conhecimento dos profissionais de enfermagem

OBJETIVO: Verificar o conhecimento da equipe de enfermagem sobre eventos adversos em pacientes em centro cirurgico, apontar possiveis causas, identificar de quem e a responsabilidade pelos mesmos e necessidade de notificacao Metodos: Pesquisa descritiva realizada por meio de questionario com dez afirmativas sobre causas para a ocorrencia de eventos adversos e quatro cenarios, conduzida com 31 profissionais de enfermagem do centro cirurgico de um hospital privado. RESULTADOS: As causas mais frequentes foram a rotina na programacao de procedimentos eletivos e comunicacao ineficaz entre a equipe de enfermagem e medica. Todos os cenarios foram identificados como eventos adversos e com necessidade de notificacao. A seguranca do paciente nao e vista como responsabilidade de toda a equipe multiprofissional. CONCLUSAO: A enfermagem deve defender os interesses dos pacientes, conhecer os riscos inerentes ao processo cirurgico e alertar os integrantes da equipe sobre os possiveis problemas que possam ocorrer.

Teaching patient safety in the medical undergraduate program at the Universidade Federal de São Paulo

Objective To analyze the Educational Project of the undergraduate medical course to verify what is taught regarding Patient Safety and to enable reflections on the educational practice. Methods A descriptive study, using document research as strategy. The document of investigation was the Educational Project of the medical course, in 2006, at the Escola Paulista de Medicina of the Universidade Federal de São Paulo. The theoretical framework adopted was the Multi-Professional Patient Safety Curriculum Guide of the World Health Organization, which led to the preparation of a list with 153 tracking terms. Results We identified 65 syllabus units in the Educational Project of the course, in which 40 (61.5%) addressed topics related to Patient Safety. Themes on the topic “Infection prevention and control” were found in 19 (47.5%) units and teaching of “Interaction with patients and caregivers” in 12 (32.5%); however content related to “Learning from errors to prevent harm” were not found. None of the framework topics had their proposed themes entirely taught during the period of education of the future physicians. Conclusion Patient safety is taught in a fragmented manner, which values clinical skills such as the diagnosis and treatment of diseases, post-treatment, surgical procedures, and follow-up. Since it is a recent movement, the teaching of patient safety confronts informative proposals based on traditional structures centered on subjects and on specific education, and it is still poorly valued.

Notificação espontânea de erros de medicação em hospital universitário pediátrico

Objective: To analyze medication errors notified at a pediatric teaching hospital in São Paulo city. Methods: Retrospective and descriptive study in which 120 error events and 115 spontaneous notifications were analyzed, between January 2007 and December 2008. Results: The error rate was 1.15 per 1000 patients-day; 27.5% of notifications referred to the school age range and the Pediatric ICU was the sector with most notifications. The error type related to wrong infusion speed predominated (25%). The human factor dimension in the performance deficit category (54%) was the most frequent cause of error events. Conclusion: The safety culture is a continuous process in institutions and the notification of adverse events is part of the strategies. Improvement measures should be incorporated based on their analysis, whether related to the review of the work process or to team trainingObjecti ve: To analyze medication errors notified at a pediatric teaching hospital in Sao Paulo city. Methods: Retrospective and descriptive study in which 120 error events and 115 spontaneous notifications were analyzed, between January 2007 and December 2008. Results: The error rate was 1.15 per 1000 patients-day; 27.5% of notifications referred to the school age range and the Pediatric ICU was the sector with most notifications. The error type related to wrong infusion speed predominated (25%). The human factor dimension in the performance deficit category (54%) was the most frequent cause of error events. Conclusion: The safety culture is a continuous process in institutions and the notification of adverse events is part of the strategies. Improvement measures should be incorporated based on their analysis, whether related to the review of the work process or to team training

Educação de pós-graduação em enfermagem à distância: avaliação sob a perspectiva dos discentes

Objetivo Avaliar os cursos de Especializacao em Gestao em Enfermagem Modalidade a Distância sob a perspectiva dos discentes. Metodos Estudo exploratorio-descritivo, com abordagem quantitativa realizado com 484 alunos concluintes. Para a avaliacao foi utilizado instrumento dividido nas categorias: local de acesso, horas de dedicacao, professores; tutores, expectativas dos alunos e avaliacao geral. A associacao entre as variaveis numericas foi realizada por meio do teste Qui-quadrado de Pearson, e a confiabilidade da medicao por meio do coeficiente Alfa de Cronbach. Resultados Os principais resultados demonstraram que os discentes se sentiram acolhidos pelos tutores e professores, e que os dois cursos contribuiram para melhorar o desempenho profissional e o desenvolvimento de competencias relacionadas a gestao. Conclusao Os cursos foram avaliados positivamente e mostraram-se uteis como ferramenta de capacitacao de Enfermeiros visando fomentar a transformacao do cenario gerencial da Enfermagem brasileira.

Erros de medicação: estudo descritivo das classes dos medicamentos e medicamentos de alta vigilância

Objective: The study aims to present the medication classes involved in medication errors occurred at an Intensive Care Unit and to identify which are classified as high-alert medication classes. Methods: The population was composed of the documents of occurrence of errors contained in a database created for a previous investigation. We performed a secondary analysis of the available information. Results: Overall, 305 events were identified, with an average rate of 6.9 events per patient. Seventy-three medications were found, distributed among 33 classes according to their predominant action, the most frequent of which were: antibiotics (25.2%), gastric acid reducers (19.0%) and antihypertensive drugs (9.2%). Thirty-seven (12.1%) events involving high-alert medication classes were identified, corresponding to five classes, among which venous anesthetics predominated (43.3%). Conclusion: These drug types are frequently used at intensive care units and should be accurately monitored, as they can cause further damage when incorrectly used.Objetivo: Este estudio presenta las clases de los medicamentos involucrados en los errores de medicacion e identifica aquellos que son clasificados como medicamentos de alto riesgo. Metodos: La poblacion fue compuesta de los documentos de las ocurrencias de errores contenidos en una base de datos de una investigacion previa. Se realizo un analisis secundario de la informacion disponible. Resultados: Fueron identificados 305 eventos, resultando en un promedio de 6,9 eventos por paciente. Fueron verificados 73 medicamentos, distribuidos en 33 clases de acuerdo con su accion predominante, siendo las mas frecuentes: antibioticos (25,2%), reductores de acidez gastrica (19,0%) y antihipertensivos (9,2%). Fueron identificadas 37 (12,1%) ocurrencias con medicamentos de alto riesgo, correspondientes a cinco clases. La incidencia con anestesicos venosos fue predominante (43,3%). Conclusion: Estos tipos de medicamentos son de uso frecuente en las Unidades de Terapia Intensiva y su monitoreo debe ser adecuado, ya que pueden causar danos mayores cuando utilizados de manera incorrecta.

Competências desenvolvidas em um curso de especialização em gestão em enfermagem à distância

OBJECTIVE: The aim of the research was to identify managerial competencies developed in nursing management distance learning specialization course, based on the responses of students who completed the course. METHODS: This was an exploratory, transversal study using a quantitative approach, with a convenience sample of 197 graduates of the first Course was conducted in eight cities within three Brazilian regions, between may and July 2009. Transcripts were analyzed using an established Brazilian theoretical framework for nursing managerial competencies. RESULTS: Participants cited 274 competencies, and identified 14 primary managerial competencies. Leadership was most frequently cited, followed by communication, knowledge acquisition and teamwork. CONCLUSION: This study identified 14 essential nursing managerial competencies for practice, and indicated a strong potential for distance learning as an educational tool to improve professional qualifications.