Poster Presentation
Monday, November 5, 2007
10:30 AM - 11:45 AM
Monday, November 5, 2007
1:30 PM - 2:45 PM
Moving towards Healthcare Quality and Patient Safety Improvement by Diagnosing the Medication System at a Brazilian University Hospital
Adriana Inocenti Miasso, PhD, Departamento de Enfermagem Psquiátrica e Ciências Humanas, University of São Paulo, Ribeirão Preto College of Nursing. WHO Collaborating Centre for Nursing Research Development, Ribeirao Preto, Brazil, Ana Elisa Bauer de Camargo Silva, Nursing Department, Faculty of Nursing of Federal University of Goias, Goiânia, Brazil, Fernanda R.E. Gimenes, Departamento de Enfermagem Geral e Especializada, University of Sao Paulo at Ribeirao Preto College of Nursing, Ribeirão Preto, Brazil, and Silvia H. De Bortoli Cassiani, DNS, RN, Departamento de Enfermagem Geral e Especializada, Escola de Enfermagem de Ribeirao Preto, Ribeirao Preto, Sao Paulo, Brazil.
| Learning Objective #1: identify the medication process in a Brazilian hospital and the problems in this system. |
| Learning Objective #2: identify improvement measures proposed by the authors. |
It is crucial for health care providers involved with medication to be familiar with its system. This descriptive study was carried out in a Central-West Brazilian teaching hospital, where the medication process was analyzed and improvement measures were proposed. Data were collected through disguised-observation; interviews made with the institution health care professionals and review of physician orders. The medication system in the hospital is characterized by prescriptions hand-writing daily in two copies; 24 hour open pharmacy and by individualized doses distribution system. Moreover, medications are prepared and administered by different nurses, there was neither a medication information center nor a formal error investigation committee. The environment was the main problem observed during prescribing (75%) and distributing (30.6%) drugs, as these occur in an inappropriate space with noise and frequent interruptions. Problems during medication preparation were also detected (45.9%) which were related to nursing procedures and anticipated preparation. 40 professionals were interviewed and they pointed the most frequent errors: physician orders (29%) and wrong time (20.6%) due to individual errors, lack of attention (47.4%) and work overload (14.5%). After that, 294 prescription orders were analyzed retrospectively, and from those 34.7% was unreadable or partially readable; 37.8% did not contain the physician’s full and readable name; bland names were found in 37.4%, and bland as well as generic names in 62.2% of them; 94.9% of prescription orders were incomplete for one or more items and 29.9% contained erasures. Suggestions made were due to creation of a multidisciplinary patient safety commission; establishment of a medication error reporting program; adopt a non-punitive culture; improve work environments; create a continuing education program; implement the computerized physician order entry, unit dose and bar code. Analyzing the medication system and its process allowed us to identify areas in which safer medication administration can occur.