Thursday, 15 July 2010
Ana Elisa Bauer de Camargo Silva, PhD
Nursing Department, Faculty of Nursing of Federal University of Goias, Goiânia, Brazil
Silvia H. De Bortoli Cassiani, DNS, RN
Department of Nursing Generality and Specialized, University of São Paulo at Ribeirão Preto, College of Nursing, Ribeirao Preto, Brazil
Adriano M. M. Reis, MSc
Department of the pharmaceutical products, University Federal de Minas Gerais, School of pharmacy, Belo Horizonte, Brazil
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
Jânia Oliveira Santos, RN
Nursing Faculty, Estácio de Sá de Goiás, Goiânia, Brazil
Learning Objective 1: The learner will be able to identify Medication Adverse Events occurred in the process of medication administration in a Brazilian hospital.
Learning Objective 2: The learner will be able to identify and to classify the medication errors occurred in the process of medication administration in a Brazilian hospital.
Purpose: To identify Medication Adverse Events occurred in the process of medication administration and to classify the medication errors (ME). Methods: Retrospective descriptive exploratory study with documental analysis conducted in an internal medicine unit at a general hospital in the city of Goiás, Brazil. Data were collected from nursing records including nursing shift reports, internal communications, orders and events which were checked for medication errors, from 2002 to 2007. The study sample involved 242 drug-related nursing notes recorded during the study period. Univariate descriptive analysis was performed using SPSS program, version 15.0.
Results: A total of 230 ME were detected. Most occurred during drug preparation and administration (64.3%). ME were described as omission error (50.9%), wrong dose error (16.5%), wrong time error (13.5%), and wrong administration technique error (12.2%). As the pharmacological class classification, a larger number of medication errors were associated to antineoplastic and immunomodulating agents (24.3%), anti-infective drugs for systemic use (20,9%) and blood and blood forming organs (15.3%) according to the Anatomical Therapeutic Chemical (ATC) classification system of WHO Collaborating Center for Drug Statistics Methodology (level 1). It was found that 43% of drugs associated to medication errors had narrow therapeutic index and 37.4% were high-alert medications.
Conclusion: Nursing records are a potential source for identifying drug-related adverse events. There needs further investigate drug use in hospital settings and to conduct a risk analysis to assess the exposure risk in patients and to implement strategies that will act as protection and prevention barriers to drug-related adverse events.
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