Errors in medicine administration - profile of medicines: knowing and preventing

Abstract

Objectives: To describe the pharmacological characteristics of medicines involved in administration errors and determine the frequency of errors with potentially dangerous medicines and low therapeutic index, in clinical units of five teaching hospitals, in Brazil. Methods: Multicentric study, descriptive and exploratory, using the non-participant observation technique (during the administration of 4958 doses of medicines) and the anatomical therapeutic chemical classification (ATC). Results: Of that total, 1500 administration errors were identified (30.3%). The administration of pharmacological groups -ATC (cardiovascular system, nervous system, alimentary tract and metabolism system and anti-infectives for systemic use) showed a higher frequency of errors. In 13.0% of errors were involved potentially dangerous medicines and in 12.2% medicines with low therapeutic index. Conclusion: The knowledge of the pharmacological profile could be an important strategy to be used in the prevention medication errors in health institutions. Keywords: Medication errors; Medication systems hospital RESUMOObjetivos: Descrever as características farmacológicas dos medicamentos envolvidos em erros de administração e determinar a frequência desses erros com medicamentos potencialmente perigosos e de baixo índice terapêutico em unidades de clínica médica de cinco hospitais de ensino brasileiros. Métodos: Estudo multicêntrico, descritivo/exploratório utilizando a técnica de observação não participante durante a administração de 4958 doses de medicamentos e a classificação anatômica terapêutica química (ATC). Resultados: Dentre esse total, foram identificados 1500 erros de administração de medicamentos (30,3%). A administração dos fármacos dos grupos ATC -sistema cardiovascular, sistema nervoso, trato alimentar e metabolismo e antinfecciosos de uso sistêmico apresentou maior frequência de erros. Em 13,0% dos erros estavam envolvidos medicamentos potencialmente perigosos e em 12,2% medicamentos de baixo índice terapêutico. Conclusão: O conhecimento do perfil farmacológico pode ser uma importante estratégia a ser utilizada na prevenção de erros de medicação em instituições de saúde. Descritores: Erros de medicação; Sistemas de medicação no hospital RESUMEN Objetivos: Describir las características farmacológicas de los medicamentos envueltos en errores de administración y determinar la frecuencia de esos errores en medicamentos potencialmente peligrosos y en los de bajo índice terapéutico, en unidades de clínica médica de cinco hospitales de enseñanza brasileños. Métodos: Estudio multicéntrico, descriptivo-exploratorio utilizando la técnica de observación no participante (durante la administración de 4.958 dosis de medicamentos) y la clasificación anatómica terapéutica química (ATC). Resultados: Fueron identificados 1500 errores de administración de medicamentos (30,3%). La administración de los fármacos de los grupos ATC (sistema cardiovascular, sistema nervioso, sistema digestivo y metabolismo, y, anti-infecciosos) de uso sist...

The Role of Pediatric Nursing Staff in the Prevention of Medication Errors

“…Literature review (14) estimated that the incidence of adverse reactions in children was 4.37% to 16.78% , similar to that found in this study (10.8%). Although national studies (15,16) claim that the wrong time is the most common medication error in health care settings, this study identified a higher frequency of wrong preparation technique. This can be justified since those studies do not seem to consider wrong preparation technique as an adverse drug event.…”

“…The knowledge of the pharmacological profile could be an important strategy to be used in the prevention of medication errors in health institutions (15,18) , and may contribute to the development of educational actions for specific types of drugs such as low therapeutic index.In this study, gentamicin and amikacin were the most involved in errors related to medication administration technique.They are two aminoglycoside antibiotics with low therapeutic index and they are also nephrotoxic and ototoxic (3) . In other countries these drugs were also associated with errors occurring in neonatal intensive care unit and pediatrics (14,19) .…”

“…Another factor that may contribute for the wrong administration time is the malfunctioning of the drug-dispensing system in the hospital pharmacy. This leads to delays in medication distribution and, consequently, in its administration (15). According to research conducted in a private hospital in São Paulo, Brazil, the second most frequent cause of errors were the nursing team's time limitations due to distractions by other patients and/or by their colleagues and emergencies occurring at the unit.…”

Metered-dose inhalers: knowledge of technicians and nursing assistants in pediatric units/Inaladores dosimetrados: conhecimento de técnicos e auxiliares de enfermagem de unidades pediátricas/Inhaladores de dosis medida: los conocimientos de los técnicos..

“…Neste contexto, estudo multicêntrico realizado em cinco hospitais brasileiro acerca dos erros de medicação identificou 1500 erros, ou seja, 30% das doses administradas continham algum erro (9) .…”

Design strategies in hospital pharmacy department: Mapping a medication system

“…According to Mendes et al (2014), such errors cause the death of 1 (one) in 131 (one hundred and thirty-one) ambulatory patients and 1 (one) in 854 (eight hundred and fifty-four) inpatients, which consists of a rate of medication errors varying from 4.8% to 5.3%. Reis et al (2010), researchers who studied the topic in Brazilian public hospitals, identified drug administration problems in 30% of cases studied.…”