Thalyta Cardoso Alux Teixeira

Análise de causa raiz: avaliação de erros de medicação em um hospital universitário

Los objetivos de este estudio consistieron en identificar y analizar los tipos de errores de medicacion observados en las dosis de medicamentos que fueron preparadas y administradas de modo diferente respecto del cual fueron prescriptas. El estudio fue de caracter descriptivo, se utilizo el metodo de analisis de causa raiz, efectuado en forma secundaria sobre los resultados de un estudio ya existente. En el estudio, 74 errores de medicacion fueron identificados durante la preparacion y la administracion de medicamentos por parte del equipo de Enfermeria. Errores de dosis (24,3%), errores de horario (22,9%) y medicamentos no autorizados (13,5%) fueron los mas frecuentes. Asi, el analisis de causa raiz fue realizado, identificandose multiples factores que contribuyeron para la ocurrencia de los errores. Fueron presentadas estrategias y recomendaciones para evitarlos.The objectives of this study were to identify and analyze the types of medication errors observed in doses prepared and administered differently from those prescribed. It is a descriptive study using the root cause analysis method, in which a secondary analysis of data from a previously existing investigation was performed. In the study, 74 medication errors were identified during medication preparation and administration by the nursing staff. Dose errors (24.3%), schedule errors (22.9%) and unauthorized medication administration errors (13.5%) were the most frequent. Hence, medication errors were identified, and root cause analysis was performed, leading to the identification of multiple factors that contributed to error occurrence. Strategies and recommendations were presented for the prevention of errors.

O sistema de medicação nos hospitais e sua avaliação por um grupo de profissionais

O objetivo do estudo foi analisar os sistemas de medicacao, em hospitais, a partir da opiniao de 107 profissionais. Em relacao as prescricoes medicas nas instituicoes, 74,8% eram manuais e 50,4% dos sistemas de distribuicao de medicamentos eram doses individualizadas. Quanto as causas dos erros na medicacao, 91% estavam associadas ao profissional. Para 61,7%, o sistema estava adequado, mas apresentando falhas. Poucos profissionais sugeriram modificacoes que favoreceriam seu trabalho. Conclui-se que ainda persiste a cultura de responsabilizar o profissional pelo erro e, tambem, a pratica de punicao, sem modificacao substancial da causa que levou ao erro.

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.

Influência da redação da prescrição médica na administração de medicamentos em horários diferentes do prescrito

OBJECTIVE: To evaluate the influence of the writing of medical orders on the administration of medications in medical units from five brazilian hospitals. METHODS: This descriptive study used a secondary analysis of data from a multicenter study conducted in 2005. the sample consisted of 1,084 medication orders that had been administered at the wrong schedule time. RESULTS: The great majority of medical orders (96.2%) had acronyms and/or abbreviations, 7.8% of them had incomplete schedules for administration of the medication, and 4.8% had been marked out. in addition, there was no schedule for the administration of the medication in 1.9% of the medical orders. CONCLUSION: Implementation of electronic prescribing and continuing education of health care providers can minimize the administration of medication at the wrong schedule time.Objective: To evaluate the influence of the writing of medical orders on the administration of medications in medical units from five brazilian hospitals. Methods: This descriptive study used a secondary analysis of data from a multicenter study conducted in 2005. the sample consisted of 1,084 medication orders that had been administered at the wrong schedule time. Results: The great majority of medical orders (96.2%) had acronyms and/or abbreviations, 7.8% of them had incomplete schedules for administration of the medication, and 4.8% had been marked out. in addition, there was no schedule for the administration of the medication in 1.9% of the medical orders. Conclusion: Implementation of electronic prescribing and continuing education of health care providers can minimize the administration of medication at the wrong schedule time. Descriptors: Medication errors; Drug prescriptions; Nursing records; Medical records

Erros de administração de antimicrobianos identificados em estudo multicêntrico brasileiro

Medication administration errors (MAE) are the most frequent kind of medication errors. Errors with antimicrobial drugs (AD) are relevant because they may interfere in patient safety and in the development of microbial resistance. The aim of this study is to analyze the AD errors detected in a Brazilian multicentric study of MAE. It was a descriptive and exploratory study carried out in clinical units in five Brazilian teaching hospitals. The hospitals were investigated during 30 days. MAE were detected by observation technique. MAE were classified in categories: wrong route(WR), wrong patient(WP), wrong dose(WD) wrong time (WT) and unordered drug (UD). AD with MAE were classified by Anatomical-Therapeutical-Chemical Classification System. AD with narrow therapeutic index (NTI) were identified. A descriptive statistical analysis was performed using SPSS version 11.5 software. A total of 1500 errors were observed, 277 (18.5%) of them were errors with AD. The types of AD error were: WT 87.7%, WD 6.9%, WR 1.5%, UD 3.2% and WP 0.7%. The number of AD found was 36. The mostly ATC class were fluoroquinolones 13.9%, combinations of penicillin 13.9%, macrolides 8.3% and third-generation cephalosporins 5.6%. The parenteral drug dosage form was associated with 55.6% of AD. 16.7% of AD were NTI. 47.4% of WD and 21.8% WT were with NTI drugs. This study shows that these errors should be considered potential areas for improvement in the medication process and patient safety plus there is requirement to develop rational drug use of AD.

IDENTIFICACIÓN Y ANÁLISIS DE LOS ERRORES DE MEDICACIÓN EN SEIS HOSPITALES BRASILEÑOS

Esta investigacion identifico, a traves del metodo de observacion directa, los errores de medicacion ocurridos en unidades de clinica medica de seis hospitales brasilenos. La muestra consistio de las dosis prescritas y administradas en las unidades y observadas durante el periodo de recoleccion de datos, obedeciendo a un minimo de 35 dosis/dia, durante 30 dias. Los resultados evidenciaron los siguientes aspectos: el 1,7% de los medicamentos administrados fue diferente de los prescritos; el 4,8% de las dosis administradas difirieron de las prescritas; el 1,5% de los medicamentos fue administrado en vias diferentes de las prescritas; el 0,3% de los pacientes recibieron medicamentos no autorizados; cerca del 7,4% de los medicamentos fue administrado mas de 1 h despues del horario previsto y el 2,2% mas de 1 h antes del prescrito.

[Root cause analysis: evaluation of medication errors at a university hospital].

Los objetivos de este estudio consistieron en identificar y analizar los tipos de errores de medicacion observados en las dosis de medicamentos que fueron preparadas y administradas de modo diferente respecto del cual fueron prescriptas. El estudio fue de caracter descriptivo, se utilizo el metodo de analisis de causa raiz, efectuado en forma secundaria sobre los resultados de un estudio ya existente. En el estudio, 74 errores de medicacion fueron identificados durante la preparacion y la administracion de medicamentos por parte del equipo de Enfermeria. Errores de dosis (24,3%), errores de horario (22,9%) y medicamentos no autorizados (13,5%) fueron los mas frecuentes. Asi, el analisis de causa raiz fue realizado, identificandose multiples factores que contribuyeron para la ocurrencia de los errores. Fueron presentadas estrategias y recomendaciones para evitarlos.The objectives of this study were to identify and analyze the types of medication errors observed in doses prepared and administered differently from those prescribed. It is a descriptive study using the root cause analysis method, in which a secondary analysis of data from a previously existing investigation was performed. In the study, 74 medication errors were identified during medication preparation and administration by the nursing staff. Dose errors (24.3%), schedule errors (22.9%) and unauthorized medication administration errors (13.5%) were the most frequent. Hence, medication errors were identified, and root cause analysis was performed, leading to the identification of multiple factors that contributed to error occurrence. Strategies and recommendations were presented for the prevention of errors.

Medication wrong-route administrations in relation to medical prescriptions

El objetivo fue analizar la influencia de la redaccion de la prescripcion medica en los errores de via de administracion ocurridos en la enfermeria de clinica medica de cinco hospitales brasilenos. Se trata de un estudio descriptivo que utilizo datos de investigacion multicentrica realizada en 2005. La poblacion fue compuesta por 1.425 errores de medicacion y la muestra por 92 errores de via. Las clases farmacologicas mas envueltas en el error fueron: 1) las cardiovasculares (31,5%), 2) las drogas que actuan en el sistema nervioso (23,9%), y 3) las que actuan en el sistema digestivo y metabolismo (13,0%). En lo que se refiere a los items de la prescripcion medica que podrian haber contribuido con los errores de via, se verifico que 91,3% de las prescripciones contenian siglas/abreviaturas; 22,8% no contenian datos del paciente, y 4,3% no presentaban fecha y contenian raspados. Errores de via son frecuentes en los hospitales brasilenos y alrededor del mundo y se sabe que estas situaciones pueden resultar en eventos adversos severos en los pacientes, incluyendo la muerte.

Patient Safety in Drug Therapy and the Influence of the Prescription in Dose Errors

The aims of this study were to analyze the redaction of the prescription in dose errors that occurred in general medical units of five Brazilian hospitals and to identify the pharmacological classes involved in these errors. This was a descriptive study that used secondary data obtained from a multicenter study conducted in 2005. The population consisted of 1,425 medication errors and the sample of 215 dose errors. Of these, 44.2% occurred in hospital E. The presence of acronyms and/or abbreviations was verified in 96.3% of prescriptions; absence of the patient registration in 54.4%; absence of posology in 18.1%; and omission of date of 0.9%. With respect to medication type, 16.8% were bronchodilators; 16.3% were analgesics; 12.1%, antihypertensives; and 8.4% were antibiotics. The absence of posology in the prescriptions may facilitate the administration of the wrong dose, resulting in inefficiency of the treatment, compromising the quality of care provided to hospitalized patients.Os objetivos foram analisar a redacao da prescricao medica nos erros de doses, ocorridos em unidades de clinica medica de cinco hospitais brasileiros, e identificar as classes farmacologicas envolvidas nesses erros. Este e estudo descritivo que utilizou dados secundarios, obtidos de pesquisa multicentrica, realizada em 2005. A populacao foi composta por 1425 erros de medicacao e a amostra por 215 erros de doses. Desses, 44,2% ocorreram no hospital E. Verificou-se presenca de siglas e/ou abreviaturas em 96,3% das prescricoes, ausencia do registro do paciente em 54,4%, falta de posologia em 18,1% e omissao da data em 0,9%. Com relacao ao tipo de medicamento, 16,8% eram broncodilatadores, 16,3% eram analgesicos, 12,1%, anti-hipertensivos e 8,4% eram antimicrobianos. A ausencia da posologia nas prescricoes pode favorecer a administracao de doses erradas, resultando em ineficiencia do tratamento, comprometendo a qualidade da assistencia prestada aos pacientes hospitalizados.

Segurança do paciente na terapêutica medicamentosa e a influência da prescrição médica nos erros de dose

The aims of this study were to analyze the redaction of the prescription in dose errors that occurred in general medical units of five Brazilian hospitals and to identify the pharmacological classes involved in these errors. This was a descriptive study that used secondary data obtained from a multicenter study conducted in 2005. The population consisted of 1,425 medication errors and the sample of 215 dose errors. Of these, 44.2% occurred in hospital E. The presence of acronyms and/or abbreviations was verified in 96.3% of prescriptions; absence of the patient registration in 54.4%; absence of posology in 18.1%; and omission of date of 0.9%. With respect to medication type, 16.8% were bronchodilators; 16.3% were analgesics; 12.1%, antihypertensives; and 8.4% were antibiotics. The absence of posology in the prescriptions may facilitate the administration of the wrong dose, resulting in inefficiency of the treatment, compromising the quality of care provided to hospitalized patients.Os objetivos foram analisar a redacao da prescricao medica nos erros de doses, ocorridos em unidades de clinica medica de cinco hospitais brasileiros, e identificar as classes farmacologicas envolvidas nesses erros. Este e estudo descritivo que utilizou dados secundarios, obtidos de pesquisa multicentrica, realizada em 2005. A populacao foi composta por 1425 erros de medicacao e a amostra por 215 erros de doses. Desses, 44,2% ocorreram no hospital E. Verificou-se presenca de siglas e/ou abreviaturas em 96,3% das prescricoes, ausencia do registro do paciente em 54,4%, falta de posologia em 18,1% e omissao da data em 0,9%. Com relacao ao tipo de medicamento, 16,8% eram broncodilatadores, 16,3% eram analgesicos, 12,1%, anti-hipertensivos e 8,4% eram antimicrobianos. A ausencia da posologia nas prescricoes pode favorecer a administracao de doses erradas, resultando em ineficiencia do tratamento, comprometendo a qualidade da assistencia prestada aos pacientes hospitalizados.