Patient Safety on the Preparation of Intravenous Mediacation in Brazilian Pediatric Cardiology Units

Purpose: The medication system in pediatric units is complex, once physiological alterations that occurs with the growth and normal development of childhood to adolescence results in dinamic transition of the medication disposal in the organism and the therapeutic response (Castilho, Nascimento & Grassi, 2016). According to Ferreira et al. (2014), the system of medication in pediatric units is frequently implemented in hospital institutions and includes multiprofessional team, above all, demands great attention, because the patients are subjected to adverse events patients caused by the professionals. Studies already developed regarding adverse events in the intravenous medication system of hospitalised children with cardiopathy, such as Azeka et al. (2014), Wilhelmsson et al. (2015). The medication system is one of the focal point that deserves attention, since it involves different processes including standardization, purchase of medication, prescription, transcription, distribution and administration. This study were considered three processes of the medication system described by Silva (2008), which can be mentioned: process of prescription, dispensation and distribution; preparation and administration of medication. As for the preparation and administration process of medication, the nursing team that is composed by nuses, nursing technicians and nursing auxiliaries is an important part of such work practices (Alomari et al., 2017). According to Feldman et al. (2017, p. 31) in Brazil is ensured in the legistation that the preparation process of medication, including the system of medication, is the Nursing team responsability of safe use of medications. In accord with Sousa (2014, p. 15), Sousa (2014, p. 23) the performance scenario of such professionals is dinamic, with simple and complex work processes, which occur simultaneously and request continous operations and decisions. Consequently, this study has the objective of identify the Nursing assistance quality in the process of intravenous medicine preparation in cardiology pediatric units of a public brazilian hospital.

Methods: It is an analytical study, with a cross-sectional design and a quantitative approach, conducted in three cardiology pediatric units, called pediatric block, of a public hospital, specialized in cardiovascular and pulmonary disease, located in Fortaleza, Ceará, Brazil. The data collection ocurred during the period of December 2017 to March 2018 throught systematic observation of the Nursing professional realizing the preparation process of intravenous medication. The observation was mediated by a checklist type of itinerary with nine operations related to preparation of medication: “check the medication label with the prescription”, “verify the integrity the wrapping”, “inspect the medicine bottle to observe any possible particular, color alteration, crack and/or leak”, “observe the medicine expiration date”, “ desinfect the ampoule bottle”, “medication reconstructed in distilled water or saline solution, respecting the principal of hospital infection prevention”, “prepared medication for administration of continuous infusion”, “identify the prepared medication” and “propely discard of used materials during the preparation”. In order to determine the amount of intravenous medication preparation to be observated a sample calculation was carried, eventually evaluating 237 preparations, which were conduted by 140 professionals of the Nursing team, among nurses and nursing technicians. The collected data were processed through the Statistical Paclage for the Social Sciences software version 20.0 and analyzed through descriptive statistics. The analysis of the Nursing quality was carried out, based on parameters used by Murassaki et al. (2013), that were determined from Positivity Ratio results. The Positivity Ratio is defined as adequadely conducted operations percentual. The Nursing assistence quality was classified according to the Positivity Ratio, which may assume the classifications: desirable (100%), proper (90 a 99%), safe (80 a 89%), boderline (71 a 79%) and low (lower or equal to 70%). The study was approved by the ethics committee.

Results: The quality of the Nursing assistence was considered, according to the sequence of observation: proper in operations “check the medication label with the prescription” (90,7%); “verify the integrity the wrapping” (92%); “identify the prepared medication” (94,9%); and “propely discard of used materials during the preparation” (99,3%). Boderline in operations “inspect the medicine bottle to observe any possible particular, color alteration, crack and/or leak” (76,6%); “observe the medicine expiration date” (76,6%); “medication reconstructed in distilled water or saline solution, respecting the principal of hospital infection prevention” (78,3%); and “prepared medication for administration of continuous infusion” (78,5%). Low in the operation “desinfect the ampoule bottle” (49,8%). No operation related to the preparation of intravenous medication archieved the Positivity Ratio desirable and safe percentage. However, there were borderline and poor results that need to be improved through training and awareness of the team on the importance of performing these actions, which may compromise the quality of care and patient safety. In a study, that analyzed the preparation and adminitration process errors of medication in pediatric patients, the preparation error rate was 67,44% and it was determined that this errors are common in the hospital and pediatrics environments, serving as indicator of quality in the service provided to the patient (Baptista, 2014). In another study, that evaluated the Nursing practice in terms of intramuscular medication administration in pediatrics, all the operations which had been carried out before the medication administration were unsatisfactory (< 70% frequency) (Souza et al., 2018). The preparation of the medication demands the interpretation of the prescription and involves a great amount of specific information on preparation and disposal of residues, considering the need of resources and workforce of the Nursing team to improve the quality and safety of the medication process, serving patients in what they effectively need, reaching higher levels of satisfaction (Costa et al., 2013).

Conclusion: This study was capable to indentify the situational diagnosis of the Nursing team, when performing the preparation process of intravenous medication in pediatric patients, corresponding a unsatisfatory assistence, which reveals that recommended actions by literature of intravenous medication administration is still a challenge to lifelong education. Therefore, it is suggested to be offered constant training to the entire Nursing team.