Poster Presentation

Monday, November 5, 2007
10:30 AM - 11:45 AM

Monday, November 5, 2007
1:30 PM - 2:45 PM
This presentation is part of : Scientific Posters
Timing Errors in Medication Administration: A Prospective Direct-Observation Study in Brazilian Hospitals
Fernanda R. E. Gimenes1, Ana Elisa Bauer de Camargo Silva2, Thalyta Cardoso Alux Teixeira1, Adriana Inocenti Miasso, PhD3, and Silvia H. De Bortoli Cassiani, DNS, RN4. (1) General and Specialized Nursing Department, University of São Paulo, Ribeirão Preto College of Nursing. WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, Brazil, (2) Nursing Department, Faculty of Nursing of Federal University of Goias, Goiânia, Brazil, (3) 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, (4) Departamento de Enfermagem Geral e Especializada, Escola de Enfermagem de Ribeirao Preto, Ribeirao Preto, Sao Paulo, Brazil
Learning Objective #1: identify the frequency of timing error committed by nurses in Brazilian hospitals and the nursing category responsible for them.
Learning Objective #2: identify the turn-shift where they occur mostly.

Medication administration errors (MAEs) are the most frequent types of medication error. They are usually classified as wrong dosage, wrong route, wrong patient, unordered drug, omission and wrong time. Wrong time has been described as one of the most frequent cause of MAEs. This multicentre exploratory study was performed to identify the frequency of this error, the nursing category involved and to determine in which turn-shift they occur most. Clinical units in five Brazilian teaching hospitals were investigated during 30 days. Time error was defined as the administration of a dose more than 60 minutes before or after the scheduled administration time, which is scheduled directly in the order by nurses or nurses technician. One nurse  per shift was selected and research assistants wrote down exactly what she/he did when administering medicines. The notes were then compared retrospectively with the physician order. A total of 4.958 doses were observed, 1.430 of them were incorrect and the most frequent type were timing error, responsible for 1.066 (74,5%) of all MAEs. 58,3% of them were administered before the schedule administration time, 55,7% were made by nurse auxiliaries; 42,8% by nurse technicians, and 1,5% by registered nurses. Those professionals were responsible for 51.1% of timing error during afternoon shift, 25.9% at night, and 22.0% in the morning. It was observed that in 27.2% doses the administration scheduled time was not present in the order. The main causes were due to the distribution of medication by pharmacy, lack of the medication at the institutions, the need of a prescription protocol for requiring drugs, lack of a pharmacy standardized distribution process and increased workload. These errors should be considered potential areas for improvement in the medication process and patient safety plus there is requirement to develop better national procedures for safe medication administration practice.