Types and frequency of errors in the preparation and administration of drugs.

Josiane Ribeiro Mendes,Cássia Regina Vancini-Campanharo,Ruth Ester Assayag Batista,Meiry Fernanda Pinto Okuno,Maria Carolina Barbosa Teixeira Lopes

doi:10.1590/s1679-45082018ao4146

Josiane Ribeiro Mendes, Cássia Regina Vancini-Campanharo + Show 3 more

Open Access

https://doi.org/10.1590/s1679-45082018ao4146

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Abstract

ABSTRACTObjective:To identify compatibility, types and frequency of errors in preparation and administration of intravenous drugs.Methods:A cross-sectional and descriptive study performed at the emergency department of a university hospital in the city of São Paulo (SP). The sample consisted of 303 observations of the preparation and administration of intravenous drugs by nursing aides, nursing technicians and registered nurses, using a systematized script, similar to a checklist. The following variables were collected: errors related to dispensing, omission, schedule, unauthorized administration, dosage, formulation, incompatibility, preparation and administration.Results:In the preparation stage, the following errors were identified: no hand hygiene (70.29%), and no use of aseptic technique (80.85%). Upon administration, no hand hygiene (81.18%), and no use of aseptic technique (84.81%). In 31.35% of observations, there was more than one medication at the same time for the same patient, of which 17.89% were compatible, 56.84% were incompatible and 25.26% were not tested, according to the Micromedex database.Conclusion:In both preparation and administration stages, the most frequent errors were no hand hygiene and no use of aseptic technique, indicating the need to develop and implement education programs focused on patient safety.

Highlights

Emergency departments are settings specialized in care of patients with acute clinical picture, which might be life-threatening conditions.[1]
400 thousand avoidable medicationrelated adverse events are reported per year at these sites.[8]. It is estimated that medication errors in hospitals cause more than 7,000 deaths per year in the United States, leading to significant costs.[9]
The study was conducted at the emergency department of Hospital São Paulo (HSP), a large high-complexity tertiary hospital that mainly cares for patients from the Sistema Único de Saúde (SUS) [Brazilian National Health System].(15)

Summary

Introduction

Emergency departments are settings specialized in care of patients with acute clinical picture, which might be life-threatening conditions.[1]. Data related to the number of healthcare-related deaths in the United States were presented, drawing attention of governmental organizations to quality of care and patient safety.[5]. It is estimated that one in every ten patients is harmed while receiving care at hospital Amidst this care, administration of medications can pose risks to the individual’s safety.[5]. 400 thousand avoidable medicationrelated adverse events are reported per year at these sites.[8] It is estimated that medication errors in hospitals cause more than 7,000 deaths per year in the United States, leading to significant costs.[9]. Data from the Instituto para Práticas Seguras no Uso de Medicamentos (ISMP) [Institute for

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Discussion

Conclusion