Medication errors in a public hospital in Brazil

Abstract

This article describes the analysis of the frequency, type and risk factors relating to errors in the preparation and administration of medications in patients admitted to a public hospital in Brasilia Federal District, Brazil, which serves a population of approximately 500,000 inhabitants. Patients are commonly affected and harmed by medication errors, almost half of which are preventable. This is a cross-sectional, descriptive and exploratory study conducted in a clinical medicine unit. Direct observations were made by eight nurse technicians. The type of error, the type of drug involved and associated risk factors were analysed. Relationships between the occurrence of errors and risk factors were studied with logistic regression models. Of the 484 observed doses, 69.5% errors occurred during drug administration, 69.6% during the preparation stage, 48.6% were timing errors, 1.7% were dose-related errors and 9.5% were errors of omission. More than one error was detected in 34.5% of occasions. Unlabelled drugs increased the risk of timing errors by a factor of 13.72. Interruptions in preparation increased the risk of errors by a factor of 3.75. Caring for a larger number of patients (8-9) increased the risk of timing errors by a factor of 8.27. The research shows the need to manage the risk of medication errors in their real-life contexts by interposing safety barriers between the hazards and potential errors.

Mapping the Medication System: Weaknesses and Risk Management

“…However, failure to comply with these actions may result in medication error, because the process, as a systemic organization, begins with the prescription and ends with proper registration and monitoring by the nursing administration [12].…”

Mapping the Medication System: Weaknesses and Risk Management

“…Some steps in the system such as checking, documentation, and monitoring were often not observed [11]. However, failure to comply with these actions may result in medication error, because the process, as a systemic organization, begins with the prescription and ends with proper registration and monitoring by the nursing administration [12].…”

Medication administration – nursing workload and patient safety in clinical wards

“…Despite the advance of new technologies, drug administration remains a complex process related to higher incident rates that can cause adverse events to patients during their hospital stay. Forty per cent of the nursing time in clinical wards is estimated to be associated with drug administration (6) , and work overload is a factor that contributes to the occurrence of errors in this process (7) .…”