High-surveillance drugs preparation and administration from the perspective of patienty safety
DOI:
https://doi.org/10.33448/rsd-v11i2.25491Keywords:
Medication errors; Potentially inappropriate medication list; Patient safety.Abstract
The preparation and administration of medications are steps in the medication system, being the last part of the process that precedes the patient. A system composed of several inputs and processes and with the participation of mid-level and higher education professionals, physicians, nurses, pharmacists and pharmacy and nursing technicians. Among the drug liability, there is a group called High-Surveillance Drugs or Potentially Dangerous Medicines, so through pharmacovigilance require more rigorous care, due to their composition and the capacity for death they have, when administered in a way erroneous. Therefore, this work aims to demonstrate the importance of the preparation and administration of type medications and its interface with patient safety. A narrative review was carried out based on a search in the Latin American Literature in Health Sciences (LILACS), BIREME and Scientific Electronic Library Online (SciELO) electronic databases, with a time frame from 2010 to 2021. After applying the criteria of inclusion and exclusion, and complete reading of the texts, 10 works were selected. The survey demonstrated the repetition of errors with AVM involving medications: heparin, fentanyl, midazolam, nalbuphine, pancuronium, dopamine, potassium chloride, tramadol, epinephrine, pethidine, morphine and also with anesthetics and electrolytes. The research demonstrated the fragility of the data recorded in the articles found, not categorizing risks in larger populations, being incipient and insignificant for a reality of the scope of the country and/or by regionality.
References
Brasil. (2013). Agência Nacional de Vigilância Sanitária – ANVISA. Resolução da Diretoria Colegiada da Anvisa – RDC nº 36, de 25 de julho de 2013. https://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2013/rdc0036_25_07_2013.html
Romero, M. P., González, R.B., Calvo, M.S.R., Fachado, A.A. (2018). A segurança do paciente, qualidade do atendimento e ética dos sistemas de saúde. Rev. Bioét. vol.26 no.3 Brasília. https://www.scielo.br/j/bioet/a/4hRnkzkJFL8MxdRByNv7LPj/?format=pdf&lang=pt
Brasil. (2014). Implantação do Núcleo de Segurança do Paciente em Serviços de Saúde – Série Segurança do Paciente e Qualidade em Serviços de Saúde. https://segurancadopaciente.com.br/wp-content/uploads/2015/09/ebook-anvisa-06-implantacao-do-nucleo-de-seguranca-do-paciente-em-servicos-de-saude.pdf
Brasil. (2013). Assistência Segura: Uma reflexão teórica aplicada à prática. Série Segurança do Paciente e Qualidade nos serviços de saúde. Vol 1. 2013. http://www.saude.pi.gov.br/uploads/divisa_document/file/374/Caderno_1_-_Assist%C3%AAncia_Segura_-_Uma_Reflex%C3%A3o_Te%C3%B3rica_Aplicada_%C3%A0_Pr%C3%A1tica.pdf
Sheikh, A., Dhingra-Kumar, N., Kelley, E., Kieny, P., Donaldson, L.J. (2017). The third global patient safety challenge :tackling medication-relatedharm. Bull World Health Organ. 2017;95:546-546A. https://pubmed.ncbi.nlm.nih.gov/28804162/
Miasso, A.I., Silva, A.E.B.C., Cassiani, S.H.B., Grou, C.R., Fakih, F.T. (2006). Erros de medicação: tipos, fatores causais e providências tomadas em quatro hospitais brasileiros. RevEscEnferm USP. 2006;40(4):524-32. https://www.scielo.br/j/reeusp/a/D8nKpL3rZYrB4KhpPnmL78L/?lang=pt
Curran, C.R., Totten, M.K. (2011). Governing for improved quality and patient safety. Nursing Economics. New Jersey jan./fev. 2011; 29, n(1):38-41. http://nursingeconomics.net/necfiles/BestonBoard/JF_11_BoB.pdf
World Health Organization. (2009). Taxonomy. The Conceptual Framework for the International Classification for Patient Safety. https://www.who.int/patientsafety/taxonomy/icps_full_report.pdf
Brasil. (2013). Protocolo de segurança na prescrição, uso e Administração de medicamentos. https://repositorio.observatoriodocuidado.org/bitstream/handle/handle/1650/protoc_identificacaoPaciente.pdf?sequence=1&isAllowed=y
Institute For Safe Medication Practices. (2018). High-Alert Medication Survey Results Lead to Several Changes for 2018. https://www.ismp.org/resources/high-alert-medication-survey-results-lead-several-changes-2018
Echer, I.C. (2001). A revisão de literatura na construção do trabalho científico. Revista gaúcha de enfermagem. https://lume.ufrgs.br/handle/10183/23470
Duarte, S.C.M., Stipp, M.A.C., Silva, M.M., Oliveira, F.T. (2015). Eventos adversos e segurança na assistência de enfermagem. Rev Bras Enferm. https://www.scielo.br/j/reben/a/mBxyRmzXxjVYbDQZfg7phyj/?format=pdf&lang=pt
Kohn, L.T., Corrigan, J.M., Donaldson, M.S. (2001). To Error is human: building a safer health system: a report of the Committee on Quality of Health Care in America.
Brasil. (2014). Manual das Organizações Prestadoras de Serviços de Saúde. Brasília: ONA.
Shaw, C., Groene, O., Moura, N., Sunol, R. (2010). Accreditation and ISO certification: do they explain differences in quality management in European hospitals? International Journal for Quality in Health Care. https://pubmed.ncbi.nlm.nih.gov/20935006/
Consórcio Brasileiro De Acreditação. (2010). Padrões de acreditação da Joint Commission Internacional para hospitais.
Brasil. (2003). RDC n°. 45, de 12 de março de 2003. https://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2003/rdc0045_12_03_2003.html
Brasil. (2013). Portaria nº 529, de 1º de abril de 2013. https://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt0529_01_04_2013.html
Silva, A.C.A.B., Rosa, D.O.S. (2016). Cultura de segurança do paciente em organização hospitalar. Cogitare Enferm. https://revistas.ufpr.br/cogitare/article/view/45583
Rommers, M.K., Teeepe-Twiss, I.M., Guchelaar, H.J. (2007). Preventing adverse drugevents in hospital practice: an overview. Pharmacoepidemiol DrugSaf. https://pubmed.ncbi.nlm.nih.gov/17610221/
Rashidee, A., Hart, J., Chen, J., Kumar, S. (2009). High-Alert Medications: Error Prevalence and Severity. Patient Safety & Quality Healthcare.
Cassiani, S.H.B., Deus, N.N., Capucho, H.C. (2011). Administración segura de medicamentos.
Joint Commission Resources. (2008). High-Alert Medications: Strategies for Improving Safety.
Brasil. (2017). Boletim Segurança do Paciente e Qualidade em Serviços de Saúde nº 15: Incidentes Relacionados à Assistência à Saúde. https://www.gov.br/anvisa/pt-br/centraisdeconteudo/publicacoes/servicosdesaude/boletim-seguranca-do-paciente/boletim-seguranca-do-paciente-e-qualidade-em-servicos-de-saude-no-15.pdf
Frederico, P.M. (2012). Interações medicamentosas potenciais dos antihipertensivos: uso perigoso entre idosos. Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública. https://www.arca.fiocruz.br/handle/icict/24287
Silva, P.L.; Cornélio, R.A.C.; Araújo, A.L.A. (2014). Farmacovigilância: conhecimento e ação dos profissionais frente a desvios de qualidade de medicamentos. Rev Bras Farm Hosp Serv Saúde. http://rbfhss.saude.ws/revista/arquivos/2014050107000475BR.pdf
Engels, M., Ciarkowski, S. (2015). Nursing, pharmacy, and prescriber knowledge and perceptions of high-alertmedications in a large, academic medical hospital. Hosp Pharm.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4585568/
Santos, G.O., Farre, A.G.M.C., Santana, I.T.S., Rocha, H.M.N., Carvalho, A.A., Santos, G.K.B.B. et al. (2020). Knowledge about the use of potentially dangerous drugs among hospital health care nurses. Rev Rene. http://periodicos.ufc.br/rene/article/view/44466
Rosa, M.B.; Perini, E.; Anacleto, T.A.; Neiva, H.M.; Bogutchi, T. (2009). Erros na prescrição hospitalar de medicamentos potencialmente perigosos. Rev Saúde Pública. https://www.scielo.br/j/rsp/a/XwLXkGKCS9g5wTTNtL6nXSh/abstract/?lang=pt#:~:text=RESULTADOS%3A%20Houve%20predom%C3%ADnio%20da%20prescri%C3%A7%C3%A3o,estavam%20pouco%20leg%C3%ADveis%20ou%20ileg%C3%ADveis.
Cortes, A.L.B.; Silvino, Z.R.; Santos, F.B.M.; Pereira, J.A.C.; Tavares, G.S. (2019). Prevalência de interações medicamentosas envolvendo medicamentos de alta-vigilância: estudo transversal. REME – Rev Min Enferm. http://reme.org.br/artigo/detalhes/1372
Smeulers, M.; Verweij, L.; Maaskant, J.M.; De Boer, M.; Krediet, C.T.P.; Nieveen Van Dijkum, E.J. et al. (2015). Quality indicators for safe medication preparation and administration: a systematic review. PLoSOne. https://pubmed.ncbi.nlm.nih.gov/25884623/
Brasil. (2020). Boletim de Farmacovigilância aborda erros de medicação. http://antigo.anvisa.gov.br/resultado-de-busca?p_p_id=101&p_p_lifecycle=0&p_p_state=maximized&p_p_mode=view&p_p_col_id=column-1&p_p_col_count=1&_101_struts_action=%2Fasset_publisher%2Fview_content&_101_assetEntryId=5765434&_101_type=content&_101_groupId=219201&_101_urlTitle=boletim-de-farmacovigilancia-aborda-erros-de-medicacao&inheritRedirect=true#:~:text=Al%C3%A9m%20de%20n%C3%A3o%20atender%20adequadamente,a%20hospitaliza%C3%A7%C3%B5es%20e%20causar%20mortes.&text=Os%20erros%20de%20medica%C3%A7%C3%A3o%20representam,precisam%20ser%20relatados%20e%20monitorados.
World Health Organization. (2017). Medicantion withoutharm: WHO global patient safety challenge. https://www.who.int/initiatives/medication-without-harm
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2022 Wylma Danuzza Guimarães Bastos; Priscila Santos Leal; Jamilly Fernanda Brito Rodrigues; Dayzyane Farias dos Santos Melo; Karina Perrelli Randau
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.
