Identificación y análisis de los errores de medicación en seis hospitales brasileños

• Silvia Helena de Bortoli Cassiani ^[1] ; Aline Aparecida Silvia Monzani ^[2] ; Ana Elisa Bauer De Camargo Silva ^[3] ; Flávio Trevisani Fakih ^[4] ; Simone Perufo Opitz ^[5] ; Thalyta Cardoso Alux Teixeira ^[6]
  1. [1] Universidad de São Paulo - EERP-USP Escuela de Enfermería
  2. [2] Pontifíca Universidade Católica Faculdade de Enfermería
  3. [3] Universidad Federal de Goiás Faculdade de Enfermería
  4. [4] Universidad Federal de São Paulo Hospital São Paulo
  5. [5] Universidad Federal de Acre
  6. [6] Universidad Federal de Acre Hospital Vera Cruz,

  Mostrar afiliaciones +
• Localización: Ciencia y enfermería, ISSN-e 0717-9553, Vol. 16, Nº. 1, 2010, págs. 85-95
• Idioma: español
• DOI: 10.4067/S0717-95532010000100010
• Títulos paralelos:
  • Identification and analysis of medication errors in six brazilian hospital
• Enlaces
  • Texto completo
• Resumen
  • español

    Esta investigación identificó, a través del método de observación directa, los errores de medicación ocurridos en unidades de clínica médica de seis hospitales brasileños. La muestra consistió de las dosis prescritas y administradas en las unidades y observadas durante el periodo de recolección de datos, obedeciendo a un mínimo de 35 dosis/día, durante 30 días. Los resultados evidenciaron los siguientes aspectos: el 1,7% de los medicamentos administrados fue diferente de los prescritos; el 4,8% de las dosis administradas difirieron de las prescritas; el 1,5% de los medicamentos fue administrado en vías diferentes de las prescritas; el 0,3% de los pacientes recibieron medicamentos no autorizados; cerca del 7,4% de los medicamentos fue administrado más de 1 h después del horario previsto y el 2,2% más de 1 h antes del prescrito.

  • English

    This study identified medication errors that occurred at the medical clinics of 6 Brazilian hospitals, using direct observation. The sample consisted of doses prescribed and administered at the clinics, which were observed during the data collection period, respecting a minimum of 35 doses/day, during a 30-day period. The results evidenced that: 1.7% of the administered medication was different from the prescribed drugs; 4.8% of the administered doses were different from the prescriptions; 1.5% of the medication was administered through routes different from the prescriptions; 0.3% of patients received non-authorized medication; about 7.4% of the medication were administered more than 1 h after and 2.2% more than 1 h before the prescribed medication time.

• Referencias bibliográficas
  • Flynn, E,Barker, KN,Pepper, G,Bates, DW,Mikeal, RL. (2002). Comparison of methods for detecting medication error in 36 hospitals and skilled:...
  • Miasso, AI,Cassiani, SHB. (2005). Administração de medicamentos: orientação final de enfermagem para a alta hospitalar. Rev Esc Enferm USP....
  • Kohn, LT,Corrigan, JM,Donaldson, MS. (2000). Committee on quality health Care in America, Institute of Medicine: To err is human: Building...
  • Cassiani, SHB. (2005). A segurança do paciente e o paradoxo no uso de medicamentos. Rev Bras Enferm.. 58. 95
  • Organização Mundial da Saúde. Declaration Pharmacists and public health.
  • Bohomol, E. Erros de medicação: causas e fatores desencadeantes sob a ótica da equipe de enfermagem. 143
  • Lee, P. (2002). Ideal principles and characteristics of a fail: safe medication-use system. Am J Health Syst Pharm. 59. 369
  • Womer, RB. (2002). Multidisciplinary systems approach to chemotherapy and holding the gains. J Clin Oncol. 20. 4705
  • Santell, JP,Hicks, RW,McMeekin, J. (2003). Medication errors: experience of United States Pharmacopea (USP) MEDMARX reporting system. J Clin...
  • National coordinating council for medication error reporting and prevention NCC Taxonomy of medication errors. NCC MERP.
  • Hatfeld, G. (1999). Rating hospitals for medication safety: a scorecard. Pharm Times. 65. 42
  • Telles Filho, PCP,Cassiani, SHB. (2004). Administração de medicamentos: aquisição de conhecimentos e habilidades requeridas por um grupo de...
  • Barker, KN,Flynn, E,Pepper, G,Bates, DW,Mikeal, RL. (2002). Medication errors observed in 36 health care facilities. Arch Intern Med.. 162....
  • Willians, NT. (2008). Medication administration through enteral feeding tubes. Am J H ealth Syst Pharm.. 65. 2347
  • Silva, AEBC,Cassiani, SHB,Miasso, AI,Optiz, SP. (2007). Problemas na comunicação: uma possível causa de erros de medicação. Acta Paul Enferm.....
  • Cometto, MC,Gómez, P. (2008). Error en la administración de medicamentos en Enfermería. Notas enferm.. 08. 29-32
  • Morais, J. (2001). A medicina doente. Isto é, S P.. 15. 48-58
  • Nadzan, DM. (1998). Medication use: a system approach to reducing errors. Oakbrook Terrace.
  • Leape, LL. (2000). Reducing adverse drug events: lessons from a breakthroughs series collaborative. Jt Comm J Qual Improv.. 26. 321
  • Cohen, MR. (2000). Medication errors: causes, prevention, and risk management. Jones and Bartlett Publishers. Washington.
  • Schneider, M P,Cotting, J,Pannatier, A. (1998). Evaluation of nurses' errors associated in the preparation and administration of medication...
  • Koop, BJ,Erstad, BL,Allen, ME,Theodorou, AA,Priestley, G. (2006). Medication errors and adverse drug events in an intensive care unit: direct...
  • Pepper, G. (2004). A segurança dos pacientes na utilização da medicação. Artes Médicas. São Paulo.
  • Monzani, AAS. A ponta do iceberg: o método de notificação de erros de medicação em um hospital geral privado no município de Campinas-SP....