Erros de medicação: quem foi?

Abstract

New diagnostic and therapeutic technologies are used with growing frequency, improving the quality of medical assistance and increasing life expectancy. Health care, however, is becoming progressively more expensive and complex. Adverse events related to medical assistance, particularly errors, are becoming public, being debated and judged in courts. Given their training, health workers are not prepared to deal with errors, which are associated with shame, fear and punishment. The approach to errors in the health system is usually individualistic, considering such events as acts of insecurity performed by careless, non-motivated and ill-trained persons. The tendency is to hide errors when they occur, with the result that an important learning opportunity is lost. There is another way to deal with errors, a systemic view that has obtained positive results in sectors such as aviation, anesthesiology and unit-dose drug distribution systems. These systems have varied degrees of safety and should take into account human limitations when designed and applied. A change in paradigm is needed when dealing with drugs, as it is not enough for a drug to have quality assurance, but the complete process of drug use should be safe. Medication errors, avoidable by definition, are at present a serious public health issue, leading to loss of lives and significant financial losses. A systemic approach to medication errors may disclose failures in the process as a whole, and improvements can be implemented to reduce their occurrence.

Práticas assistenciais para segurança do paciente em unidade de terapia intensiva

“…(7) In the intensive care unit, where patients' clinical conditions range between narrow limits of normality/abnormality, where small organic changes can lead to severe impairment of body functions, the risk is greater. (2,8) The occurrence of errors is not only undesirable, but also harmful, thereby the issue of care safety and the context in which care is delivered is inevitably related to the assessment of health services. (9) Nursing work in the intensive care unit is described as stressful, wearing, fatiguing and overloading, especially regarding the working hours and the environment.…”

Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

“…The characteristics of the system may heighten the risk of mistakes and worsen the consequences of these mistakes. In this sense, it is important to assess risk and damage to patients in the search for ultimate patient safety (Rosa, Perini, 2003). The World Health Organization definition of patient safety establishes that unnecessary harm or potential harm associated with healthcare should be reduced to an acceptable minimum (WHO, 2009).…”

Terminologia de incidentes com medicamentos no contexto hospitalar

“…Alguns autores notam que a variedade de termos resultante propicia divergências nos resultados das publicações e, na prática diária, pode confundir outros profissionais, os quais muitas vezes não sabem como classificar um evento que presenciam ou que irão notificar. Com isso, impede-se o conhecimento do verdadeiro impacto provocado pelos incidentes associados a medicamentos, permanecendo o obstáculo a uma visão real do problema 8,9,10,11 .…”