| Learning Objective #1: Discuss the importance of identification of the patient to prevent medication error and to increase the patient safety | |||
| Learning Objective #2: Determine the systems factors involved in the identification of patients in an international reality to prevent medication errors |
Introduction:Brazil has a small number of nurses, and they are not enough for the integral care of hospitalized patients. Nursing aides and auxiliaries are responsible for patient care, preparation and administration of medication. One of the most common errors is the administration of medication to wrong patient. Objective : The objective of the investigation was to determine the systems factors involved in the identification of patients. A simple analysis showed that the identification of patients in the hospital was poor. Some had a piece of paper fixed to their beds on which their names and medical specialty were written and others did not have it. Also auxiliaries often did not follow policies such as asking the patient’s name. Strategies to change: The strategies for changing this situation involved auxiliaries and their supervisors. At first, a seminar on patient’s safety was conducted with national and international guests. This seminar discussed various strategies to reduce medication errors . Next, a small group was formed in the clinics in which they discussed error cases, interventions and revision of punitive practices. Results: A small change in the auxiliaries’ attitudes was observed. They now seem less fearful of reporting cases and an increase in the number of error reports, more effective use of patient identification bands as well as a more open discussion among professionals and supervisors concerning medication errors have been observed. Next steps: The next steps are to carry out a global analysis of the medication system, aiming at locating flaws and at the implementation of practices that already proven to prevent errors, such as the implementation of the unitary dose and review of the clinical pharmacist’s role. Also it is necessary to implement a non-punitive reporting system hazards and accidents and policies to the identification of patients by auxiliaries.
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