Prevalencia de errores en la preparación y administración de medicamentos intravenosos en adultos: Metaanálisis con metarregresión
DOI:
https://doi.org/10.33448/rsd-v13i1.44834Palabras clave:
Errores de medicación; Infusiones intravenosas; Administración intravenosa; Enfermeras practicantes; Seguridad del paciente; Atención hospitalaria.Resumen
Objetivo: Evaluar la prevalencia promedio de errores en la preparación y administración de medicamentos intravenosos en un hospital mediante un metanálisis. Método: Revisión sistemática mediante metanálisis con metarregresión, registrado en PROSPERO (CRD42022324431), con búsqueda en las siete bases de datos, utilizando el Rayyan QCRY®. La calidad metodológica de los estudios seleccionados se evaluó mediante la Escala de Newcastle-Ottawa. El metanálisis se calculó utilizando el modelo de efectos aleatorios y se ajustó por la inversa de la varianza, y se realizaron análisis para investigar la heterogeneidad. Resultados: Se incluyeron 34 estudios primarios. La prevalencia estimada de errores en la preparación y administración de medicamentos intravenosos fue del 41,23% (IC95% 30,51-51,96; I2 = 100,00%). Conclusión: Los resultados reflejan la falta de datos oficiales de los sistemas de salud sobre el reporte de errores en las instituciones, base para estrategias efectivas que garanticen la seguridad del paciente en el proceso de medicación.
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Abbasinazari, M., Hajhossein Talasaz, A., Mousavi, Z. & Zare-Toranposhti, S. (2013). Evaluating the frequency of errors in preparation and administration of intravenous medications in orthopedic, general surgery and gastroenterology wards of a teaching hospital in Tehran. Iranian journal of pharmaceutical research: IJPR. 12(1), 229-34. https://www.ncbi.nlm.nih.gov/pubmed/24250594.
Alomi, Y. A., Alghamdi, S. J. & Alattyh, R. A. (2019) National Medication Errors Reporting System at Ministry of Health in Saudi Arabia. Pharmacology, Toxicology and Biomedical Reports, 5(1):4-7. 10.5530/PTB.2019.5.2
Anselmi, M. L., Peduzzi, M. & Santos, C. B. (2007). Errors in the administration of intravenous medications in Brazilian hospitals. Journal of Clinical Nursing. 16, 1839–1847. 10.1111/j.1365-2702.2007.01834.x
Berdot, S., Sabatier, B., Gillaizeau, F., Caruba, T., Prognon, P. & Durieux, P. (2012). Evaluation of drug administration errors in a teaching hospital. BMC Health Serv Res.12:60. https://doi.org/10.1186/1472-6963-12-60 .
Billstein-Leber, M., Carrillo, J. D., Cassano, A. T, Moline, K. & Robertson, J. J. (2018). ASHP Guidelines on Preventing Medication Errors in Hospitals. AJHP: official journal of the American Society of Health-System Pharmacists. 75(19), 1493-517. https: / /doi.org/10.2146/ajhp170811.
Blandford, A., Furniss, D., Lyons, I., Chumbley, G., Iacovides, I., Wei, L., Cox, A., Mayer, A., Schnock, K., Bates, D. W., Dykes, P. C., Bell, H. & Franklin, B. D. (2016). Exploring the Current Landscape of Intravenous Infusion Practices and Errors (ECLIPSE): protocol for a mixed-methods observational study. BMJ Open. 3;6(3):e009777. 10.1136/bmjopen-2015-009777
Brazil. Ministry of Health (BR). (2013). Establishes the National Patient Safety Program (PNSP). Ordinance n. 529, de 1ª April of 2013. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt0529_01_04_2013.html.
Brazil. Ministry of Health (BR). (2021). SUS hospital information system. tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/cnv/qiuf.def.
Burger, M. & Degnan, D. (2019). Comparative Safety, Efficiency, and Nursing Preference Among 3 Methods for Intravenous Push Medication Preparation: A Randomized Crossover Simulation Study. J Patient Saf. 15(3), 238-245. 10.1097/PTS.0000000000000269
Cousins, D. H., Sabatier, B., Begue, D., Schmitt, C. & Hoppe-Tichy, T. (2005). Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France. Qual Saf Health Care. 14(3), 190-5. 10.1136/qshc.2003.006676
Couto, R. C., Pedrosa, T. M. G., Roberto, B. A. D., Daibert, P. B., Abreu, A. C. C. & Leão. M. L. (2018). Yearbook of Hospital Care Safety in Brazil. Institute for Studies in Supplementary Health. 99. https://repositorio.observatoriodocuidado.org/bitstream/handle/handle/1646/Anuario2018_IESS.pdf?sequence=1&isAllowed=y.
Ding, Q., Barker, K. N., Flynn, E. A, Westrick, S. C, Chang, M, Thomas, R. E. & Braxton-Lloyd, K. (2015). Incidence of intravenous medication errors in a Chinese Hospital. Value Health Reg Issues. 6,33 – 9. https://doi.org/10.1016/j.vhri.2015.03.004.
Fahimi, F., Ariapanah, P., Faizi, M., Shafaghi, B., Namdar, R. & Ardakani, M. T. (2008). Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: an observational study. Aust Crit Care. 21(2), 110-6. http://dx.doi.org/10.1016/j.aucc.2007.10.004 .
Fekadu, T., Teweldemedhin, M., Esrael, E. & Asgedom, S. W. (2017). Prevalence of intravenous medication administration errors: a cross-sectional study. Integr Pharm Res Pract. 6, 47-51. http://dx.doi.org/10.2147/IPRP.S125085 .
Feleke, S. A., Mulatu, M. A. & Yesmaw, Y. S. (2015). Medication administration error: magnitude and associated factors among nurses in Ethiopia. BMC Nursing. 14:53. https://doi.org/10.1186/s12912-015-0099-1 .
Figueredo, I. B., Bizzaria, F. P de A. & Albuquerque, N. L. S. de. (2022). Types of errors in the preparation and administration of intravenous medications: integrative literature review. Journal Sustinere. 9(2), 537-563. https://doi.org/10.12957/sustinere.2021.55356 .
Han, P. Y., Coombes, I. D. & Green, B. (2005). Factors predictive of intravenous fluid administration errors in Australian surgical care wards. Qual Saf Health Care. 14(3), 179-84. http://dx.doi.org/10.1136/qshc.2004.010728.
Helmons, P. J., Wargel, L. N. & Daniels, C. E. (2009). Effect of bar-code-assisted medication administration on medication administration errors and accuracy in multiple patient care areas. Am J Health-Syst Pharm. 66, 1202–1210. 10.2146/ajhp080357
Hertig, J. B., Degnan, D. D., Scott, C. R., Lenz, J. R., Li, X. & Anderson, C. M. (2018). A comparison of error rates between intravenous push methods: A prospective, multisite, observational study. Journal of Patient Safety. 14(1), 60-5. 10.1097/PTS.0000000000000419.
Higgins, J. P., Thompson, S. G., Deeks, J. J. & Altman, D. G. (2003). Measuring inconsistency in meta-analyses. BMJ (Clinical research ed.). 6;327(7414), 557-60. https://pubmed.ncbi.nlm.nih.gov/12958120/>. https://doi.org/10.1136/bmj.327.7414.557.
Hoefel, H. H. & Lautert, L. (2006). Errors committed by nursing technicians and assistants in administering antibiotics. American journal of infection control. 34(7), 437-42. http://dx.doi.org/10.1016/j.ajic.2005.08.011.
Hunter, J. P., Saratzis, A., Sutton, A. J., Boucher, R. H., Sayers, R. D. & Bown, M. J. (2014). In meta-analyses of proportion studies, funnel plots were found to be an inaccurate method of assessing publication bias. Journal of clinical epidemiology. 67(8),897-903. https://doi.org/10.1016/j.jclinepi.2014.03.003.
Husch, M., Sullivan, C., Rooney, D., Barnard, C., Fotis, M., Clarke, J. & Noskin, G. (2005). Insights from the sharp end of intravenous medication errors: implications for infusion pump technology. Quality & safety in health care. 14(2), 80-6. http://dx.doi.org/10.1136/qshc.2004.011957.
Infusion Nurses Society (INS). (2016). Infusion therapy standards of practice. Journal of Infusion Nursing. 39(1s):1-156.
Institute for Safe Medicine Use Practices. ISMP. (2018). Global patient safety challenge harm-free medication. 8(1), 1-8. ISMP Brazil Bulletin. https://www.ismp-brasil.org/site/boletins/.
Kohn, L. T., Corrigan, J. M., Donaldson, M. S., editors. Institute of Medicine (US) (2000). Committee on Quality of Health Care in America; To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US). https://doi.org/10.17226/9728.
Jessurun, J. G, Hunfeld, N. G. M., de Roo, M., Van Onzenoort, H. A. W, Van Rosmalen J, Van Dijk M &Van den Bemt PMLA. (2023). Prevalence and determinants of medication administration errors in clinical wards: A two-centre prospective observational study. Journal of clinical nursing. 32(1-2), 208-220. 10.1111/jocn.16215
Lima Neto, A. V., Silva, F. A., Brito, G. M. O. L., Elias, T. M. N., Sena, B. A. C. & Oliveira, R. M. (2019). Analysis of adverse event reports in a private hospital. Enfermeria global. 18(55), 314-43. https://doi.org/10.6018/eglobal.18.3.325571.
Lyons, I., Furniss, D., Blandford, A., Chumbley, G., Iacovides, I., Wei, L., Cox, A., Mayer, A., Vos, J., Galal-Edeen, G. H., Schnock, K. O., Dykes, P. C., Bates, D. H. & Franklin, B. D. (2018). Errors and discrepancies in the administration of intravenous infusions: a mixed methods multihospital observational study. BMJ Quality & Safety. 27, 892-901. https://qualitysafety.bmj.com/content/27/11/892. https://doi.org/10.1136/bmjqs-2017-007476.
McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D. & et al. (2020). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. http://prisma-statement.org/PRISMAStatement/PRISMAStatement.aspx.
Mendes, J. R., Lopes, M. C. B. T., Vancini-Campanharo, C. R., Okuno, M. F. P. & Batista, R. E. A. (2018). Types and frequency of errors in the preparation and administration of drugs. Einstein (São Paulo). 16 (3), eAO4146. https://doi.org/10.1590/s1679-45082018ao4146.
National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). (2018). What is a medication error? Nova York: National Coordinating Council for Medication Error Reporting and Prevention. https://source.yiboshi.com/20170417/1492425631944540325.pdf.
Nguyen, H. T., Nguyen, T. D., Van den Heuvel, E. R., Haaijer-Ruskamp, F. M. & Taxis, K. (2015). Medication errors in vietnamese hospitals: prevalence, potential outcome and associated factors. PLoS One. 10(9), e0138284. https://doi.org/10.1371 / journal.pone.0138284.
Ong, W. M. & Subasyini, S. Medication errors in intravenous drug preparation and administration. (2013). The Medical journal of Malaysia. 68(1),52-57. Available from:< https://www.ncbi.nlm.nih.gov/pubmed/23466768 >.
Owens, K., Palmore, M., Penoyer, D. & Viers, P. (2020). The Effect of Implementing Bar-Code Medication Administration in an Emergency Department on Medication Administration Errors and Nursing Satisfaction. Journal of emergency nursing. 46(6), 884-891. 10.1016/j.jen.2020.07.004
Pena, M. M. & Melleiro, M. M. (2017). The root cause analysis method for investigating adverse events. Journal of Nursing UFPE on line. 11(12), 5297-304. https://periodicos.ufpe.br/revistas/index.php/revistaenfermagem/article/download/25092/25481/76650 >.
Reason, J. Human error: models and management. BMJ. [Internet]. 2000. 320(7237):768-70. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770/ >.
Rodriguez-Gonzalez, C. G., Herranz-Alonso, A., Martin-Barbero, M. L., Duran-Garcia, E., Durango-Limarquez, M. I., Hernández-Sampelayo, P. & Sanjurjo-Saez, M. (2012). Prevalence of medication administration errors in two medical units with automated prescription and dispensing. Journal of the American Medical Informatics Association: JAMIA. 19(1), 72-8. DOI: https://doi.org/10.1136/amiajnl-2011-000332 .
Romero, C. M., Salazar, N., Rojas, L., Escobar, L., Griñén, H., Berasaín, M. A., Tobar, E. & Jirón, M. (2013). Effects of the implementation of a preventive interventions program on the reduction of medication errors in critically ill adult patients. Journal of critical care. 28(4), 451-60. 10.1016/j.jcrc.2012.11.011
Santos, C. M. da C., Pimenta, C. A. de M., & Nobre, M. R. C. (2007). The PICO strategy for constructing the research question and searching for evidence. Latin American Nursing Journal, 15(3), 508-511. https://doi.org/10.1590/S0104-11692007000300023
Schnock, K. O., Dykes, P. C., Albert, J., Ariosto, D., Call, R., Cameron, C., Carroll, D. L., Drucker, A. G., Fang, L., Garcia-Palm, C. A., Husch, M. M., Maddox, R. R., McDonald, N., McGuire, J., Rafie, S., Robertson, E., Saine, D., Sawyer, M. D., Smith, L. P., Stinger, K. D., Vanderveen, T. W., Wade, E., Yoon, C. S., Lipsitz, S. & Bates, D. W. (2017). The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study. BMJ Qual Saf. 26(2),131-140. http://dx.doi.org/10.1136/bmjqs-2015-004465.
Serafim, C. T. R., Dell’A. M. C. Q., Castro, M. C. N., Spiri, W. C. & Nunes, H. R. C. (2017). Severity and workload related to adverse events in the ICU. Brazilian Nursing Magazine. 70(5),942-48. https://doi.org/10.1590/0034-7167-2016-0427.
Silva, L. D. & Camerini, F. G. (2012). Analysis of the administration of intravenous medications in a Sentinela Network hospital. Nursing Context Text. 21(3), 633-641. http://dx.doi.org/10.1590/S0104-07072012000300019.
Silva, H. P. da & Elias, F. T. S. (2019). Incorporation of technologies into the health systems of Canada and Brazil: perspectives for advances in evaluation processes. Public Health Journal. 35(2), e00071518. https://doi.org/10.1590/0102-311X00071518.
Siman, A., Drumond, A. T. V. B., Amaro, M. & de-Carvalho, C. (2021). Medication error: conceptions and behaviors of the nursing team members. Research Journal Care is Fundamental Online. 13(0),109-16. https://doi.org/10.9789/2175-5361.rpcfo.v13.7853.
Skog, J., Rafie, S., Schnock, K. O., Yoon, C., Lipsitz, S. & Lew, P. (2022). The Impact of Smart Pump Interoperability on Errors in Intravenous Infusion Administrations: A Multihospital Before and After Study. Journal Patient Safety 18(3), e666-e671. 10.1097/PTS.0000000000000905
Souza, D. O. (2020). Under the leadership of the World Bank: challenges in, and perspectives of, the SUS counter-reform. Physis: Public Health Journal. 30(1):e300101. https://doi.org/10.1590/S0103-73312020300101
Taxis, K. & Barber, N. (2003). Ethnographic study of incidence and severity of intravenous drug errors. BMJ. 326(7391):684. http://dx.doi.org/10.1136/bmj.326.7391.684.
Volpe, C. R. G., Pinho, D. L. M., Stival, M. M. & Oliveira, G. K. M. (2014). Medication errors in a public hospital in Brazil. British journal of nursing (Mark Allen Publishing). 23(11):552, 553-9. http://dx.doi.org/10.12968/bjon.2014.23.11.552 .
Wells, G., Shea, B. O., Connell, D., Peterson, J., Welch, V., Losos, M., et al. (2021). The Newcastle-Ottawa (NOS) Quality Assessment Scale for Case-Control and Cohort Studies: Ottawa Hospital Research Institute. https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp .
Westbrook, J. I., Rob, M. I., Woods, A. & Parry, D. (2011). Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Qual Saf. 20(12), 1027-34. https://doi.org/10.1136/bmjqs-2011-000089 .
Wirtz, V., Taxis, K. & Barber, N. D. (2003). An observational study of intravenous medication errors in the United Kingdom and in Germany. Pharm World Sci. 5(3):104-11. 10.1023/a:1024009000113
Wiseman, M. L., Poole, S., Ahlin, A. & Dooley, M. J. (2018). Reducing intravenous infusion errors: an observational study of 16 866 patients over five years. J Pharm Pract Res. 1(48), 49-55. https://onlinelibrary.wiley.com/doi/abs/10.1002/jppr.1339. 10.1002/jppr.1339.
World Health Organization (WHO). (2017). Medication without harm: WHO’s third global patient safety challenge. Geneva: WHO. http://www.who.int/patientsafety/medication-safety/en/.
Wright, K. R, Dekarske, B., Clark, J. S. & Chaffee, B. W. (2019). Parenteral product error detection before and after implementation of intravenous workflow management technology. Journal of Oncology Pharmacy Practice 1, 5-15. 10.1177/1078155217723695
Yousef, A. M., Abu-Farha, R. K., Abu-Hammour, K. M. (2022). Detection of medication administration errors at a tertiary hospital using a direct observation approach.Journal of Taibah University Medical Sciences. 17(3),433-440. 10.1016/j.jtumed.2021.08.015
Zingg, W. & Pittet, D. (2009). Peripheral venous catheters: an under-evaluated problem. International Journal of Antimicrobial Agents. 1(1), 38-42. https://doi.org/10.1016/S0924-8579(09)70565-5.
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