Notifications of medication errors in a general hospital of urgency and emergency
DOI:
https://doi.org/10.33448/rsd-v10i7.16528Keywords:
Medication errors; Patient safety; Notification.Abstract
Drug-related adverse events can result in socioeconomic repercussions and harm to patients. Thus, the study aimed to evaluate the notifications of medication errors made to the Patient Safety Center of an emergency and emergency hospital in the interior of Bahia. Cross-sectional, descriptive-analytical study carried out in a public emergency and emergency hospital. Data were collected from adverse event notifications made during three months of collection. The type and classification of the error were as determined. The Kolmogorov-Smirnov test was used to assess the normality of the continuous variables, considering p> 0.05 as normal distribution, and to compare the proportions of the categorical variables, Pearson's chi-square test and Fisher's exact test were used. 151 notifications of medication errors were identified, classified by type: prescription (51.7%), administration (45.7%) and dispensing (2.6%). These classifications, 12 classifications, being the most frequent: incorrect dose (42.4%), medication omission (26.5%) and administration time (7.9%). The highest occurrence of errors was in the Intensive Care Unit (46.4%). The drug classes most involved with errors were those related to the alimentary tract and metabolism, cardiovascular system and anti-infectives for systemic use. Among the notifying professionals, pharmacists were the ones who performed the most notifications. In view of the identified notifications and considering that medication errors are preventable events, efforts are necessarily made in the search for more information for a better assessment and knowledge of the consequences and possible damages related to medication errors.
References
Alves, M. de F. T., Carvalho, D. S. de, & Albuquerque, G. S. C. de. (2019). Motivos para a não notificação de incidentes de segurança do paciente por profissionais de saúde: revisão integrativa. Ciência & Saúde Coletiva, 24(8), 2895-2908. https://dx.doi.org/10.1590/1413-81232018248.23912017
Anacleto, T. A., Rosa, M. B., Miranda, H. M., & Martins, M. A. P. (2010). Erros de medicação. Site Conselho Federal de Farmácia. http://www.cff.org.br/sistemas/geral/revista/pdf/124/encarte_farmaciahospitalar.pdf
Brasil. Agência Nacional de Vigilância Sanitária. Bulário Eletrônico. Disponível em: https://consultas.anvisa.gov.br/#/bulario/
Brasil. Ministério da Saúde. Resolução 466/12. O Plenário do Conselho Nacional de Saúde resolve aprovar diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. 2012.
Brock, D., Abu-Rish, E., Chiu, C., Hammer, D., Wilson, S.; Vorvick, L., Blondon, K., Schaad, D., Liner, D. & Zierler, B. (2013). Interprofessional education in team communication: working together to improve patient safety. BMJ Qual Saf., 22, 414-23
CFF. Conselho Federal de Farmácia. (2018, January 16). Informações sobre medicamentos, apenas de fontes seguras. Conselho Federal de Farmácia Site. https://www.cff.org.br/noticia.php?id=4786
Da Silva, E. F., de Faveri, F., & Lorenzini, L. (2014). Errores de medicación en el ejercicio de la enfermería: una revisión integrativa. Enfermería Global, 13(34), 330-337. Recuperado en 19 de mayo de 2021, de http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S169561412014000200016&lng=es&tlng=es
Farzi, S., Farzi, S., & Alimohammadi, N. (2016). Medication errors by the Intensive care units’nurses and the preventive strategies. JAP, 33–45. http://jap.iums.ac.ir/article-1-5231-en.html
Farzi, S., Irajpour, A., Saghaei, M., & Ravaghi, H. (2017). Causes of Medication Errors in Intensive Care Units from the Perspective of Healthcare Professionals. Journal of research in pharmacy practice, 6(3), 158–165. https://doi.org/10.4103/jrpp.JRPP_17_47
Farzi, S., Saghaei, M., Irajpour, A., & Ravaghi, H. (2018). The most frequent and important events that threaten patient safety in intensive care units from the perspective of health-care professionals'. Journal of research in medical sciences: the official journal of Isfahan University of Medical Sciences, 23, 104. https://doi.org/10.4103/jrms.JRMS_140_18
Ferreira, F. S., Pereira, T. A., Souza, B. P., & Sanches, A. C. C. (2021) The pharmacist’s role in preventing medication errors. Research, Society and Development, [S. l.], 10(3), e18310313280, 2021. DOI: 10.33448/rsd-v10i3.13280.
Garfield, S., Barber, N., Walley, P., Willson, A., & Eliasson, L. (2009). Quality of medication use in primary care--mapping the problem, working to a solution: a systematic review of the literature. BMC Med. Published. https://doi.org/10.1186/1741-7015-7-50
Garrouste-Orgeas, M., PHILIPPART, F., Bruel, C., Max, A., Lau, N., & Misset, B. (2012). Overview of medical errors and adverse events. Ann Intensive Care. Published. https://doi.org/10.1186/2110-5820-2-2
Irajpour, A., Farzi, S., Saghaei, M, & Ravaghi, H. (2019) Effect of interprofessional education of medication safety program on the medication error of physicians and nurses in the intensive care units. J Edu Health Promot, 8, 196.
Karimian, Z., Kheirandish, M., Javidnikou, N., Asghari, G., Ahmadizar, F., Dinarvand, R. (2018). Medication Errors Associated With Adverse Drug Reactions in Iran (2015-2017): A P-Method Approach. International Journal of Health Policy and Management, 7(12), 1090-1096. doi: 10.15171/ijhpm.2018.91
Loureiro, R. J., Roque, F., Rodrigues, A. T., Herdeiro, M. T., & Ramalheira, E. (2016). O uso de antibióticos e as resistências bacterianas: breves notas sobre a sua evolução. Revista Portuguesa de Saúde Pública, 34, 77–87. https://doi.org/10.1016/j.rpsp.2015.11.003
Maher, R. L., Hanlon, J., & Hajjar, E. R. (2014). Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf, 13, 57–65. https://doi.org/10.1517/14740338.2013.827660
Meira, G. M.; Souza, T. S.; Lemos, L. B. & Lemos, G. S. (2020). Prescription and administration errors of antimicrobials in a pediatric inpatient unit. Rev Bras Farm Hosp Serv Saude, 11(4):0502.
Mendes, J. R.; Lopes, M. C. B. T.; Vancini-Campanharo, C. R.; Okuno, M. F. P. & Batista, R. E. A. (2018). Tipos e frequência de erros no preparo e na administração de medicamentos endovenosos. Einstein (São Paulo) [online]. 16 (3), eAO4146. http://dx.doi.org/10.1590/s1679-45082018ao4146.
Miasso, A. I., Grou, C. R., Cassiani, S. H. B., Silva, Ana Elisa Bauer de Camargo, & Fakih, Flávio Trevisan. (2006). Erros de medicação: tipos, fatores causais e providências tomadas em quatro hospitais brasileiros. Revista da Escola de Enfermagem da USP, 40(4), 524-532. https://dx.doi.org/10.1590/S0080-62342006000400011
National Coordinating Council for Medication Error Reporting and Prevention. (NCCMERP). What is a medication error? Nova York: National Coordinating Council for Medication Error Reporting and Prevention; 2015. http://www.nccmerp.org/aboutmedication-errors, acessado em 19 de março de 2019.
Néri, E. D. R., Gadêlha, P. G. C., Maia, S. G., Pereira, A. G. S.; Almeida, P. C., Rodrigues, C. R. M., Portela, P. M. & Fonteles, M. M. F. (2011). Erros de prescrição de medicamentos em um hospital brasileiro. Rev Assoc Med Bras, 57, 306–314.
Newbould, V., Le Meur, S., Goedecke, T., & Kurz, X. (2017). Medication errors: a characterization of spontaneously reported cases in eudravigilance. Drug Saf, 40, 1241–1248. https://doi.org/10.1007/s40264-017-0569-3
OMS. Organização Mundial de Saúde. (2019). Índice químico terapêutico anatômico (ATC) com doses diárias definidas (DDDs). WHO Collaborating Centre for Drug Statistics Methodology Site. http://www.whocc.no/atcddd
OMS. Organização Mundial de Saúde. Medication without harm: WHO’s third global patient safety challenge. Geneva: WHO, [2017]. Disponível em: <http://www.who.int/patientsafety/medication-safety/en/>. Acesso em: 17 setembro 2019
Pereira, A. S., Shitsuka, D. M., Parreira, F. J., & Shitsuka, R. (2018). Metodologia da pesquisa científica (1ª ed.): Universidade Federal de Santa Maria, Núcleo de Tecnologia Educacional. https://repositorio.ufsm.br/bitstream/handle/1/15824/Lic_Computacao_Metodologia-Pesquisa-Cientifica.pdf?sequence=1>. Acesso em: 07 junho 2021.
Ribeiro, A. E. C. & Novaes, C. de O. (2019) Characterization of incidents in a Federal Public Hospital between the years 2014 and 2019. Research, Society and Development, [S. l.], 10(4), e30510414080, 2021. DOI: 10.33448/rsd-v10i4.14080.
Santi, T., Beck, C. L. C., da Silva, R. M.; Zeitoune, R. G., Tonel, J. Z. & do Reis, D. A. Martins. (2014). Erro de medicação em um hospital universitário: percepção e fatores relacionados. Enfermería Global, 13, 160–183.
Secretaria Estadual de Saúde da Bahia (SESAB). Regiões de Saúde do Estado da Bahia: Municípios da Região de Saúde Jequié. 2018. Disponível em: <http://www1.saude.ba.gov.br/mapa_bahia/result_REGIAO_SAUDEch.asp?REGIAO_SAUDE=Jequi%E9>. Acesso em: 12 maio 2021.
Silva, A. E. B. C., Reis, A. M. M., Miasso, A. I., Santos, J. O., & Cassiani, S. H. B. (2011). Adverse drug events in a sentinel hospital in the State of Goiás, Brazil. Revista Latino-Americana de Enfermagem, 19(2), 378-386. https://dx.doi.org/10.1590/S0104-11692011000200021
Silva, J. S. D. S.; Almeida, P. H. R. F.; Perini, E.; Pádua, C. A. M.; Rosa, M. B. & Lemos, G. S. (2017). Erros de prescrição e administração envolvendo um medicamento potencialmente perigoso. Rev Enferm UFPE on Line, 11, 3707–3717.
Suculupe, S., Martinez-Zapata, M.J., Mancebo, J., Font-Vaquer, Assumpta., Castillo-Masa, A.M., Viñolas, I., Morán, I. & Robleda, Gemma. (2020). Medication errors in prescription and administration in critically ill patients. Journal of Advanced Nursing. Published. https://doi.org/10.1111/jan.14322
Valle, M. M. F., Cruz, E. D. A. & Santos, T. (2017). Incidentes com medicamentos em unidade de urgência e emergência: análise documental. Revista Da Escola de Enfermagem Da USP, 51. https://doi.org/10.1590/s1980-220x2016033303271
Watanabe, J. H., Mcinnis, T. & Hirsch, J. D. (2018). Cost of Prescription Drug–Related. Morbidity and Mortality. Annals of Pharmacotherapy, 1–9.
Williams, D. J. P. (2007). Medication errors. Journal-Royal College of Physicians of Edinburgh, 37.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2021 Diana Silva Lopes; Ana Mercia Silva Mascarenhas; Nara Jacqueline Souza dos Santos; Tamiles Daiane Borges Santana; Tuany Santos Souza; Julita Maria Pereira Borges; Gisele da Silveira Lemos
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
1) Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
2) Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
3) Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.