Types and frequency of errors in the preparation and administration of drugs

ABSTRACT Objective: To identify compatibility, types and frequency of errors in preparation and administration of intravenous drugs. Methods: A cross-sectional and descriptive study performed at the emergency department of a university hospital in the city of São Paulo (SP). The sample consisted of 303 observations of the preparation and administration of intravenous drugs by nursing aides, nursing technicians and registered nurses, using a systematized script, similar to a checklist. The following variables were collected: errors related to dispensing, omission, schedule, unauthorized administration, dosage, formulation, incompatibility, preparation and administration. Results: In the preparation stage, the following errors were identified: no hand hygiene (70.29%), and no use of aseptic technique (80.85%). Upon administration, no hand hygiene (81.18%), and no use of aseptic technique (84.81%). In 31.35% of observations, there was more than one medication at the same time for the same patient, of which 17.89% were compatible, 56.84% were incompatible and 25.26% were not tested, according to the Micromedex database. Conclusion: In both preparation and administration stages, the most frequent errors were no hand hygiene and no use of aseptic technique, indicating the need to develop and implement education programs focused on patient safety.

[1]  Marismary Horsth De Seta,et al.  Avaliao dos servios hospitalares de emergncia do programa QualiSUS , 2009 .

[2]  Agência Nacional de Vigilância Sanitária.  Assistência segura: uma reflexão teórica aplicada à prática , 2013 .

[3]  A. M. Reis,et al.  Adverse drug events in a sentinel hospital in the State of Goiás, Brazil. , 2011, Revista latino-americana de enfermagem.

[4]  Regina Célia de Oliveira,et al.  Estratégias para prevenção de erros de medicação no setor de emergência , 2005 .

[5]  M. Pedreira,et al.  Erros de medicação em pediatria , 2011 .

[6]  Danitza Passamai Rojas Buvinich.  Ouvidoria: uma análise de sua utilização como ferramenta de gestão no âmbito da Agência Nacional de Vigilância Sanitária (Anvisa). , 2009 .

[7]  R. Martins,et al.  Potential intravenous drug incompatibilities in a pediatric unit , 2016, Einstein.

[8]  Nicholas Christenfeld,et al.  Increase in US medication-error deaths between 1983 and 1993 , 1998, The Lancet.

[9]  Sabina Gainotti,et al.  Nonurgent patients in the emergency department? A French formula to prevent misuse , 2010, BMC health services research.

[10]  Lindemberg Assunção Costa,et al.  ERRORES DE DESPACHO DE MEDICAMENTOS EN UN HOSPITAL PÚBLICO PEDIÁTRICO , 2008 .

[11]  S. H. Cassiani,et al.  [Strategies for prevention of medication errors in emergengy services]. , 2005, Revista brasileira de enfermagem.

[12]  A. E. B. D. C. Silva,et al.  Eventos adversos a medicamentos em um hospital sentinela do Estado de Goiás, Brasil , 2011 .

[13]  Dominik Aronsky,et al.  Crowding delays treatment and lengthens emergency department length of stay, even among high-acuity patients. , 2009, Annals of emergency medicine.

[14]  C. R. Vancini-Campanharo,et al.  Nursing care based on risk assessment and classification: agreement between nurses and the institutional protocol. , 2013, Revista latino-americana de enfermagem.

[15]  C. Oliveira,et al.  Erros na administração de medicamentos na prática assistencial da equipe de enfermagem: uma revisão sistemática , 2016 .

[16]  Chih-Jung Chen.  Medication errors in pediatrics. , 2013, Pediatrics and neonatology.

[17]  surda de Brasília.  UNIVERSIDADE DE BRASÍLIA , 2006 .

[18]  Loli Silva,et al.  Segurança do paciente: análise do preparo de medicação intravenosa em hospital da rede sentinela , 2011 .

[19]  Jarbas Maia Linhares.  Diario Oficial da União , 2019 .

[20]  F. Bottega,et al.  Pain as the fifth vital sign: use of the assessment scale by nurses in general hospital , 2010 .

[21]  Lolita Dopico da Silva,et al.  Patient safety: analysing intravenous medication preparation in a sentinel network hospital in brazil , 2011 .

[22]  Gabriella Novelli Oliveira,et al.  Acogimiento con evaluación y clasificación de riesgo: concordancia entre los enfermeros y el protocolo institucional , 2013 .

[23]  Cintia Monteiro,et al.  Interrupciones de actividades de enfermeros y la seguridad del paciente: revisión integradora de la literatura , 2015 .

[24]  L. Costa,et al.  Medication dispensing errors at a public pediatric hospital. , 2008, Revista latino-americana de enfermagem.

[25]  S. Cassiani,et al.  Seguridad del paciente en la terapéutica medicamentosa y la influencia de la prescripción médica en los errores de dosis , 2010 .

[26]  Rosane Teresinha Fontana,et al.  A dor como quinto sinal vital: utilização da escala de avaliação por enfermeiros de um hospital geral , 2010 .

[27]  H. Manasse,et al.  Increase in US medication-error deaths , 1998, The Lancet.