21
views
0
recommends
+1 Recommend
1 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Erro de medicação: importância da notificação no gerenciamento da segurança do paciente Translated title: Medication errors: importance of notification in the management of patient safety Translated title: Error de medicación: la importancia de la notificación para la seguridad del paciente

      research-article

      Read this article at

      ScienceOpenPublisher
      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          A notificação dos erros de medicação é um instrumento importante para o gerenciamento da qualidade da assistência e segurança do paciente. Este estudo objetivou verificar junto à equipe de enfermagem o seu entendimento do que é um erro de medicação e apresentar a sua opinião quanto à notificação deste evento. Foi realizada um survey descritivo/exploratória com 89 profissionais cujos resultados demonstraram uma ausência de uniformidade na compreensão do que é um erro de medicação e quando ele deve ser notificado ao médico ou preenchido o relatório de ocorrências. Concluímos que há necessidade de se desenvolver programas educacionais que elucidem o que são os erros de medicação, discutindo cenários para entender as causas do problema com propostas de melhoria.

          Translated abstract

          Notifying medication errors is an important instrument in managing assistance quality and safety for the patient. The objective of this study was to verify with the nursing team their understanding that a medication error had been committed, and to observe how they notified responsible physicians of the event. To achieve this, researchers used a descriptive/exploratory survey with 89 professionals. The results demonstrate a lack of uniformity in understanding that medication errors had been committed, when these errors must be communicated to a physician, and when an event report must be filled out. The research shows the necessity to develop educational programs that shed light on exactly what constitutes a medication error, clarifying causes of the problem and providing solutions to solve it.

          Translated abstract

          La notificación de los errores en la medicación es un instrumiento importante para la gerencia en lo que se refiere a la calidad de la asistencia y seguridad del paciente. Este estudio tiene como objetivo verificar junto al equipo de la enfermaría el entendimiento del mismo sobre lo que es un error de medicación y presentar su opinión referente a la notificación de este evento. Fue realizado un survey descriptivo/exploratorio con 89 profesionales cuyos resultados demostraron una no-uniformidad en la comprensión de lo que es un error de medicación y cuando este debe ser notificado al medico o notificado en el relatorio de ocurrencias. Concluimos que hay necesidades de sé desenvolver programas educacionales que esclarezcan lo que son errores de medicación, discutiendo escenarios para entender las causas del problema con propuestas de mejoría.

          Related collections

          Most cited references17

          • Record: found
          • Abstract: found
          • Article: not found

          Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities.

          The validity and cost-effectiveness of three methods for detecting medication errors were examined. A stratified random sample of 36 hospitals and skilled-nursing facilities in Colorado and Georgia was selected. Medication administration errors were detected by registered nurses (R.N.s), licensed practical nurses (L.P.N.s), and pharmacy technicians from these facilities using three methods: incident report review, chart review, and direct observation. Each dose evaluated was compared with the prescriber's order. Deviations were considered errors. Efficiency was measured by the time spent evaluating each dose. A pharmacist performed an independent determination of errors to assess the accuracy of each data collector. Clinical significance was judged by a panel of physicians. Observers detected 300 of 457 pharmacist-confirmed errors made on 2556 doses (11.7% error rate) compared with 17 errors detected by chart reviewers (0.7% error rate), and 1 error detected by incident report review (0.04% error rate). All errors detected involved the same 2556 doses. All chart reviewers and 7 of 10 observers achieved at least good comparability with the pharmacist's results. The mean cost of error detection per dose was $4.82 for direct observation and $0.63 for chart review. The technician was the least expensive observer at $2.87 per dose evaluated. R.N.s were the least expensive chart reviewers at $0.50 per dose. Of 457 errors, 35 (8%) were deemed potentially clinically significant; 71% of these were detected by direct observation. Direct observation was more efficient and accurate than reviewing charts and incident reports in detecting medication errors. Pharmacy technicians were more efficient and accurate than R.N.s and L.P.N.s in collecting data about medication errors.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            Drug-related problems in hospitalised patients.

            Drug-related problems include medication errors (involving an error in the process of prescribing, dispensing, or administering a drug, whether there are adverse consequences or not) and adverse drug reactions (any response to a drug which is noxious and unintended, and which occurs at doses normally used in humans for prophylaxis, diagnosis or therapy of disease, or for the modification of physiological function). Furthermore, adverse drug events can be defined as an injury--whether or not causally-related to the use of a drug. Drug-related problems are relatively common in hospitalised patients and can result in patient morbidity and mortality, and increased costs. In order to get an overview of studies on drug-related problems in hospitalised patients, with specific attention to the incidence of drug-related problems and their costs, to the possibilities of prevention and to the effect of these interventions, we performed a literature search. Incidences of medication errors reported in studies vary widely. The range of reported incidences of adverse drug reactions is even wider. These wide ranges can be largely explained by the different study methods and definitions used. Problems related to drug therapy may be averted by preventive interventions. Several possibilities for prevention exist, especially for the prevention of medication errors. Prescribing, transcription and interpretation errors can be reduced by using computerised physician order entry. Together with the use of automated dispensing systems and bar-code technology, this will aid in the reduction of both dispensing and administration errors. Education of nursing staff involved in the process of drug distribution is another important measure for preventing medication errors. Finally, the introduction of systems for the early detection of adverse drug reactions may help to reduce problems related to drug therapy. Identifying risk factors that contribute to the development of adverse drug reactions, may aid in the prevention of these reactions.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: not found

              Nurses' perceptions: when is it a medication error?

              This study investigates nurses' perceptions of medication errors and appropriate reporting. Results of the study suggest that nurses may not report because of fear of reprisal. Further, there may be a need to allow for nursing judgment in some instances; at those time, the term "medication error" may not be the most appropriate. Implications for nursing administration include further exploration of nonpunitive processes in response to adverse drug events.
                Bookmark

                Author and article information

                Journal
                reben
                Revista Brasileira de Enfermagem
                Rev. Bras. Enferm.
                Associação Brasileira de Enfermagem (Brasília, DF, Brazil )
                0034-7167
                1984-0446
                February 2007
                : 60
                : 1
                : 32-36
                Affiliations
                [02] São Paulo SP orgnameUNIFESP orgdiv1Departamento de Enfermagem laisramos@ 123456denf.epm.br
                [01] São Paulo SP orgnameUNIFESP orgdiv1Departamento de Enfermagem ebohomol@ 123456denf.epm.br
                Article
                S0034-71672007000100006 S0034-7167(07)06000106
                10.1590/S0034-71672007000100006
                1509fce6-e5ed-46ca-9a83-a17ec7a24c9d

                This work is licensed under a Creative Commons Attribution 4.0 International License.

                History
                : 13 July 2006
                : 19 October 2006
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 17, Pages: 5
                Product

                SciELO Revista de Enfermagem

                Categories
                Pesquisa

                Safety management,Enfermagem,Gerenciamento de segurança,Qualidade,Erros de medicação,Enfermería,Administración de la seguridad,Calidad,Errores de medicación,Nursing,Quality,Medication errors

                Comments

                Comment on this article