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This exploratory study analyzed the medication preparation and administration process in medical-clinical units at four Brazilian hospitals located in the Southeast, Central-West and Northeast, identified problems that can contribute to the occurrence of medication errors and proposed improvement measures. Data were collected through non-participant and direct observation of nursing professionals' activities during one week. The results revealed the following main problems: the environment in Hospital B; preparation errors related to technique and anticipated medication preparation in C and D; technical, communication and patient identification mistakes in Hospital A. Suggestions to achieve greater quality and safety in patient care include the constitution of a multidisciplinary commission to evaluate the system, nursing discussion groups, environmental improvements, permanent courses and training and actual presence of a nurse during the process.

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OBJETIVO: Este estudo descritivo identificou e analisou pontos frágeis da comunicação durante a realização da prescrição, dispensação e administração de medicamentos na unidade de clínica médica e farmácia de um hospital universitário. MÉTODOS: Os dados foram coletados através de observações diretas durante 21 dias; revisões de 294 prescrições de medicamentos e 40 entrevistas com profissionais. RESULTADOS: A análise identificou prescrições incompletas, com abreviaturas, e realizadas sob interrupções e distrações. Na dispensação, as requisições apresentaram falhas no preenchimento dos formulários; na administração de medicamentos os problemas referiam-se ao uso de etiquetas transcritas para o preparo da medicação e falta de comunicação entre profissionais de enfermagem e paciente. CONCLUSÃO: Os meios de comunicação utilizados devem ser revistos, a fim de que se crie um sistema de medicação seguro para o paciente.

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This study analyzed the causes, types, administrative measures taken and suggestions concerning medication errors according to the perspective of professionals involved with the medication systems in four Brazilian hospitals. It is an exploratory, survey-type, multicentric study. The sample consisted of professionals from the medical clinic and pharmacy in the above-mentioned hospitals. Semistructured interviews were used for data collection. Results showed that the most frequently error types mentioned by the professionals were related to medication ordering/transcription. Lack of attention, individual mistakes and problems in service management were the major causes of errors. Reports were the main measures taken in view of errors, and changes in individual attitudes were the most frequently mentioned form to prevent them.

Objective: To understand the feelings of nursing professionals who have committed medication errors. Methods: Descriptive and exploratory study with a qualitative approach. The subjects were 15 nursing professionals from a university hospital in Goiânia. Data were collected by interviews guided by a semi-structured instrument, which were recorded and analyzed according to the premises of Bardin. Results:The results showed that the most common feelings are panic, despair, fear, guilt and shame, among others. The coping strategies they adopt include looking for someone to share the problem, formally communicating the error and looking for information and knowledge. Conclusion: Hospitals should not ignore that human beings can err, but turn this into a motive to implement systemic strategies, such as the review of medication processes, ideal work conditions, psychological support and investment in continuing education. Keywords: Medication errors/psychology; Nurses/psychology; Feelings; Behavior RESUMO Objetivo: Conhecer os sentimentos dos profissionais de enfermagem que cometeram erro de medicação. Métodos: Estudo descritivo, qualitativo, realizado com 15 profissionais de enfermagem de um hospital universitário de Goiânia. Os dados foram coletados através de entrevistas semi-estruturadas, gravadas e analisadas segundo os pressupostos de Bardin. Resultados: Os resultados mostraram que os sentimentos mais comuns são pânico, desespero, medo, culpa, vergonha, entre outros. Adotam, como estratégias de enfretamento buscar alguém para compartilhar o problema, realizar comunicação formal do erro e buscar informação e conhecimento. Conclusão: Os hospitais não devem negligenciar a falha do ser humano, mas fazer disso um motivo para a implementação de estratégias sistêmicas como a revisão dos processos de medicação, condições ideais de trabalho, apoio psicológico e investimento em educação continuada. Descritores: Erros de medicação/psicologia; Enfermeiras/psicologia; Sentimentos; Conduta RESUMEN Objetivo: Conocer los sentimientos de los profesionales de enfermería que cometieron error en la medicación. Métodos: Se trata de un estudio descriptivo, cualitativo, realizado con 15 profesionales de enfermería de un hospital universitario de Goiânia. Los datos fueron recolectados a través de entrevistas semi-estructuradas, grabadas y analizadas según las premisas de Bardin. Resultados: Los resultados mostraron que los sentimientos más comunes son pánico, desesperación, miedo, culpa, vergüenza, entre otros. Adoptan, como estrategias de enfretamiento buscar a alguien para compartir el problema, realizar comunicación formal del error y buscar información y conocimiento. Conclusión: Los hospitales no deben descuidar la falla del ser humano, sino hacer de ello un motivo para la implementación de estrategias sistémicas como la revisión de los procesos de medicación, condiciones ideales de trabajo, apoyo psicológico e inversión en educación continuada.

This was a retrospective, descriptive and documental study with the aim of identifying adverse drug events which occurred in the medication administration process and to classify these medication errors. This study was developed in the internal medicine unit of a general hospital of Goiás, Brazil. Report books used by nursing staff from the period 2002 to 2007, were analyzed. A total of 230 medication errors were identified, most of which occurred in the preparation and administration of the medications (64.3%). Medication errors were of omission (50.9%), of dose (16.5%), of schedule (13.5%) and of administration technique (12.2%) and were more frequent with antineoplastic and immunomodulating agents (24.3%) and anti-infective agents (20.9%). It was found that 37.4% of drugs were high alert medications. Considering the medication errors detected it is important to promote a culture of safety in the hospital.