COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDY

Gabriela Machado Ezaias Paulino,Alexsandro De Oliveira Dias,Laura Misue Matsuda,Luiz Fernando Da Silva,Alessandra Cristina Gobbi Matta,Andressa Martins Dias Ferreira

doi:10.1590/1980-265x-tce-2020-0045

Abstract

ABSTRACT Objectives to characterize accidents/falls and medication errors in the care process in a teaching hospital and to determine their root causes and variable direct costs. Method cross-sectional study implemented in two stages: the first, was based on the analysis of secondary sources (notifications, medical records and cost reports) and the second, on the application of root-cause analysis for incidents with moderate/severe harm. The study was carried out in a teaching hospital in Paraná, which exclusively serves the Brazilian Unified Health System and composes the Network of Sentinel Hospitals. Thirty reports of accidents/falls and 37 reports of medication errors were investigated. Descriptive statistical analysis and the methodology proposed by The Joint Commission International were applied. Results among the accidents/falls, 33.3% occurred in the emergency room; 40.0% were related to the bed, in similar proportions in the morning and night periods; 51.4% of medication errors occurred in the hospitalization unit, the majority in the night time (32.4%), with an emphasis on dose omissions (27.0%) and dispensing errors (21.6%). Most incidents did not cause additional harm or cost. The average cost was R$ 158.55 for the management of falls. Additional costs for medication errors ranged from R$ 31.16 to R$ 21,534.61. The contributing factors and root causes of the incidents were mainly related to the team, the professional and the execution of care. Conclusion accidents/falls and medication errors presented a low frequency of harm to the patient, but impacted costs to the hospital. Regarding root causes, aspects of the health work process related to direct patient care were highlighted.

Highlights

IntroductionThe theme of patient safety gained worldwide notoriety after the publication of the report “To err is human”, prepared by the Institute of Medicine (IOM) of the National Academy of Medicine of the United States of America (USA), in the late 1990s.1
Even after the global alert promoted by the Institute of Medicine (IOM) report and the subsequent campaigns of the World Health Organization (WHO), with the objective of favoring the development of public policies in the field of patient safety 1, recent data show that care incidents remain a serious public health problem, due to the thousands of patients who are victims of unsafe practices and/or low quality of care.[2]
In order to monitor the worldwide mobilization for the promotion of harm-free health care, the Brazilian Ministry of Health (MS) established the National Patient Safety Program (NPSP)[3], through Ordinance No 529/2013, which aims to qualify health care

Summary

Introduction

The theme of patient safety gained worldwide notoriety after the publication of the report “To err is human”, prepared by the Institute of Medicine (IOM) of the National Academy of Medicine of the United States of America (USA), in the late 1990s.1. Even after the global alert promoted by the IOM report and the subsequent campaigns of the World Health Organization (WHO), with the objective of favoring the development of public policies in the field of patient safety 1, recent data show that care incidents remain a serious public health problem, due to the thousands of patients who are victims of unsafe practices and/or low quality of care.[2]. Among the main incidents related to health, those related to nursing care such as medication errors, pressure injuries, accidents/falls, infections, losses or inadequate use of medical-hospital devices, low adhesion to hand hygiene and others are highlighted.[5,6,7]

Objectives

Methods

Results

Discussion

Conclusion