Este estudo transversal teve como objetivos: caracterizar os erros de medicação relatados por profissionais de enfermagem que atuam em UTI; comparar os dados sócio-demográficos, do trabalho e da qualidade de vida relacionada à saúde (QVRS) dos profissionais envolvidos e não envolvidos com erros de medicação em UTI; verificar se os domínios da QVRS são fatores independentes associados aos erros de medicação em UTI. Foram pesquisados 94 profissionais de enfermagem de três UTIs (duas de adultos e uma pediátrica) de um hospital privado do município de São Paulo, sendo 39 enfermeiros (41,5%) e 55 técnicos de enfermagem (58,5%). Os dados socio-demográficos, do trabalho e os relacionados aos erros de medicação foram registrados em instrumentos próprios. A QVRS foi avaliada com a versão em português do instrumento SF-36. Os profissionais foram comparados em dois grupos, segundo o relato de terem ou não cometido erros de medicação nas quatro semanas anteriores à pesquisa. Regressão logística univariada e múltipla foram utilizadas para análise da relação entre as variáveis. A maioria dos profissionais era do sexo feminino (79,8%), com idade média de 33 anos (dp=6,45), casada ou com companheiro (52,1%). A renda familiar per capita foi de R$ 2.024,95 (dp=1.625,00); 52,1% tinham apenas um vínculo empregatício. Entre os 18 profissionais que mencionaram ter cometido erro, seis eram enfermeiros e 12, técnicos de enfermagem. Houve notificação do erro em 61,1% dos casos. Os erros mais freqüentes foram os da fase de administração (67,8%). Entre os profissionais que cometeram erros, todos os escores do SF-36 foram significativamente menores. Na análise múltipla, o domínio Aspectos Emocionais e os turnos de trabalho da tarde e da noite mostraram associação significativa com erro de medicação, como fatores de proteção. Os resultados deste estudo trazem subsídios para a adoção de medidas institucionais especificamente direcionadas às necessidades dos profissionais de enfermagem, contribuindo, desta forma, para uma assistência mais segura aos pacientes / This cross-sectional study aimed to characterize the medication errors reported by the nursing professionals who work in ICU; to compare the socio-demographic data of the labor and the health-related quality of life (HRQL) of professionals involved and not involved with medication errors in ICU; and to check whether the domains of HRQL are independent factors associated with medication errors in ICUs. We studied 94 nursing professionals in three ICUs (two adult and one pediatric) in a private hospital in the city of Sao Paulo, with 39 nurses (41.5%) and 55 nursing technicians (58.5%). Socio-demographic data of the labor and the ones related to medication errors were recorded in separate instruments. The HRQL was assessed with the Portuguese version of the SF-36 instrument. The professionals were compared in two groups, according to the report of having committed or not medication errors in the four weeks preceding the survey. Univariable and multiple logistic regressions were used to analyze the relationship between the variables. Most practitioners were female (79.8%) with average age of 33 years (SD = 6.45), married or with partner (52.1%). The per capita income was R$ 2024.95 (SD = 1625.00), 52.1% had only one job. Among the 18 practitioners who reported having committed error, six were nurses and 12 were nursing technicians. There was notification of the error in 61.1% of the cases. The most frequent errors were the ones of the administration stage (67.8%). Among those who committed errors, all of the SF-36 scores were significantly lower. In multiple analysis, the domain Emotional Aspects and the work shifts of the afternoon and night showed significant association with medication errors as factors of protection. The results of this study provide subsidies for the adoption of institutional measures specifically targeted to the needs of nursing professionals, thus contributing to a safer care of patients

Este estudo transversal teve como objetivos: caracterizar os erros de medicação relatados por profissionais de enfermagem que atuam em UTI; comparar os dados sócio-demográficos, do trabalho e da qualidade de vida relacionada à saúde (QVRS) dos profissionais envolvidos e não envolvidos com erros de medicação em UTI; verificar se os domínios da QVRS são fatores independentes associados aos erros de medicação em UTI. Foram pesquisados 94 profissionais de enfermagem de três UTIs (duas de adultos e uma pediátrica) de um hospital privado do município de São Paulo, sendo 39 enfermeiros (41,5%) e 55 técnicos de enfermagem (58,5%). Os dados socio-demográficos, do trabalho e os relacionados aos erros de medicação foram registrados em instrumentos próprios. A QVRS foi avaliada com a versão em português do instrumento SF-36. Os profissionais foram comparados em dois grupos, segundo o relato de terem ou não cometido erros de medicação nas quatro semanas anteriores à pesquisa. Regressão logística univariada e múltipla foram utilizadas para análise da relação entre as variáveis. A maioria dos profissionais era do sexo feminino (79,8%), com idade média de 33 anos (dp=6,45), casada ou com companheiro (52,1%). A renda familiar per capita foi de R$ 2.024,95 (dp=1.625,00); 52,1% tinham apenas um vínculo empregatício. Entre os 18 profissionais que mencionaram ter cometido erro, seis eram enfermeiros e 12, técnicos de enfermagem. Houve notificação do erro em 61,1% dos casos. Os erros mais freqüentes foram os da fase de administração (67,8%). Entre os profissionais que cometeram erros, todos os escores do SF-36 foram significativamente menores. Na análise múltipla, o domínio Aspectos Emocionais e os turnos de trabalho da tarde e da noite mostraram associação significativa com erro de medicação, como fatores de proteção. Os resultados deste estudo trazem subsídios para a adoção de medidas institucionais especificamente direcionadas às necessidades dos profissionais de enfermagem, contribuindo, desta forma, para uma assistência mais segura aos pacientes / This cross-sectional study aimed to characterize the medication errors reported by the nursing professionals who work in ICU; to compare the socio-demographic data of the labor and the health-related quality of life (HRQL) of professionals involved and not involved with medication errors in ICU; and to check whether the domains of HRQL are independent factors associated with medication errors in ICUs. We studied 94 nursing professionals in three ICUs (two adult and one pediatric) in a private hospital in the city of Sao Paulo, with 39 nurses (41.5%) and 55 nursing technicians (58.5%). Socio-demographic data of the labor and the ones related to medication errors were recorded in separate instruments. The HRQL was assessed with the Portuguese version of the SF-36 instrument. The professionals were compared in two groups, according to the report of having committed or not medication errors in the four weeks preceding the survey. Univariable and multiple logistic regressions were used to analyze the relationship between the variables. Most practitioners were female (79.8%) with average age of 33 years (SD = 6.45), married or with partner (52.1%). The per capita income was R$ 2024.95 (SD = 1625.00), 52.1% had only one job. Among the 18 practitioners who reported having committed error, six were nurses and 12 were nursing technicians. There was notification of the error in 61.1% of the cases. The most frequent errors were the ones of the administration stage (67.8%). Among those who committed errors, all of the SF-36 scores were significantly lower. In multiple analysis, the domain Emotional Aspects and the work shifts of the afternoon and night showed significant association with medication errors as factors of protection. The results of this study provide subsidies for the adoption of institutional measures specifically targeted to the needs of nursing professionals, thus contributing to a safer care of patients

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Το mHealth, η χρήση δηλαδή φορητών τεχνολογιών για την βελτίωση των παρεχόμενων υπηρεσιών υγείας, είναι σήμερα ένα από τα πιο ταχέως αναπτυσσόμενα πεδία της ηλεκτρονικής υγείας (eHealth). Ο αριθμός των επαγγελματιών υγείας που υιοθετούν έξυπνα κινητά τηλέφωνα (smartphones) για την εκτέλεση πληθώρας λειτουργιών αυξάνεται συνεχώς, εξαιτίας των δυνατοτήτων και της φορητότητας που αυτά παρέχουν. Ταυτόχρονα, τα σφάλματα στη φαρμακευτική αγωγή είναι από τα πιο συνηθισμένα ιατρικά λάθη με επιπτώσεις τόσο στην υγεία του ασθενούς όσο και στις δαπάνες στην υγεία. Η χορήγηση φαρμάκων είναι μια πολύπλοκη διαδικασία, καθώς απαιτεί από τον ειδικό της υγείας την ανάλυση πληθώρας παραγόντων και την ανάκτηση, επεξεργασία και διαχείριση μεγάλου όγκου πληροφορίας. Σύμφωνα με τη βιβλιογραφία, η χρήση τεχνολογιών πληροφορικής για την υποβοήθηση των επαγγελματιών υγείας στη λήψη αποφάσεων κατά τη συνταγογράφηση, μπορεί να συμβάλει σημαντικά στη μείωση των σφαλμάτων φαρμακευτικής αγωγής. Στο πλαίσιο της παρούσας διπλωματικής εργασίας, προχωρήσαμε στη διερεύνηση και αξιολόγηση των σημαντικότερων εφαρμογών έξυπνων κινητών συσκευών για το φάρμακο, με στόχο την εξαγωγή χρήσιμων συμπερασμάτων για τα χαρακτηριστικά και τις λειτουργίες που ενσωματώνουν. Ένα από τα βασικά συμπεράσματα της έρευνας ήταν η απουσία αντίστοιχης εφαρμογής για τα φάρμακα που είναι εγκεκριμένα από τον Εθνικό Οργανισμό Φαρμάκων (ΕΟΦ). Ως εκ τούτου, προχωρήσαμε στο σχεδιασμό και την ανάπτυξη εφαρμογής για τον έλεγχο ασυμβασιών μεταξύ φαρμάκων, η οποία παρέχει επιπλέον τη δυνατότητα προβολής πληροφοριών συνταγολογίου για τα φάρμακα του ΕΟΦ. Ο σχεδιασμός της εφαρμογής έγινε λαμβάνοντας υπόψη τις ανάγκες και τις απαιτήσεις μελλοντικών χρηστών, όπως οι επαγγελματίες υγείας και οι ασθενείς, προκειμένου να διασφαλιστεί η λειτουργικότητα και η ευχρηστία της. Η εν λόγω εφαρμογή προορίζεται για έξυπνες κινητές συσκευές που διαθέτουν λειτουργικό σύστημα Android, ενώ η πληροφορία που ενσωματώνει βασίζεται αποκλειστικά στο εθνικό συνταγολόγιο του ΕΟΦ. / Mobile Health or mHealth, namely the use of mobile and wireless technologies in order to improve health services and achieve health goals, is today one of the most rapidly expanding fields of electronic health (eHealth). The number of health professionals that adopt smartphones to perform multiple tasks, during their everyday medical practice, is increasing constantly. This is due to the fact that smartphones provide advanced computing capabilities and high portability. Simultaneously, medication errors are among the most common medical errors which have negative impact both for the health of the patient and the expenditure on health sector. Drug prescribing is quite a complex procedure, considering the fact that requires the health expert to analyze multiple factors and retrieve, process, manage and digest large volume of information. According to the literature, the use of information technologies to assist health professionals in decision-making when prescribing drugs, can contribute significantly to the reduction of medication errors. In the context of our work, we explored and evaluated the major smartphone applications for drugs, aiming to the extraction of useful conclusions about the features and functions that they incorporate. One of the research key findings was the absence of a corresponding application for the drugs that are approved by the National Drug Organization of Greece. Therefore, we design and develop an application for checking drug-drug interactions which additionally provides the ability to view national formulary information about drugs. The analysis and design of the application was implemented in collaboration with future users, such as health professionals and patients, in order to ensure that will meet their needs and requirements and at the same time will remain user friendly. This application is intended for Android smart mobile devices (e.g. smartphones, tablet PCs) and the information that integrates is solely based on the national formulary of the National Drug Organization of Greece.

Renny Varghese Impact of an Electronic Medical Record Implementation on Drug Allergy Overrides in a Large Southeastern HMO Setting (Under the direction of Russell Toal, Associate Professor) Electronic medical records (EMRs) have become recognized as an important tool for improving patient safety and quality of care. Decision support tools such as alerting functions for patient medication allergies are a key part of reducing the frequency of serious medication problems. Kaiser Permanente Georgia (KPGA) implemented its EMR system in the primary care departments at Kaiser's twelve facilities in the greater metro Atlanta area over a six month period beginning in June 2005 and ending December 2005. The aim of this study is to analyze the impact of the EMR implementation on the number of drug allergy overrides within this large HMO outpatient setting. Research was conducted by comparing the rate of drug allergy overrides during pre and post EMR implementation. The timeline will be six months pre and post implementation. Observing the impact of the incidence rate of drug allergy alerts after the implementation provided insight into the effectiveness of EMRs in reducing contraindicated drug allergies. Results show that the incidence rate of drug allergy overrides per 1,000 filled prescriptions rose by a statistically significant 5.9% (ñ > 0.0002; 95% CI [-1.531, -0.767]) following the implementation. Although results were unexpected, several factors are discussed as to the reason for the increase. Further research is recommended to explore trends in provider behavior, KPGA specific facilities and departments, and in other KP regions and non-KP healthcare settings. INDEX WORDS: electronic medical records, drug allergy overrides, patient safety, medication errors, decision support tools, outpatient setting, primary care, computerized provider order entry

Medication administration constitutes a key element of acute care delivery, while errors in the process threaten patient safety. The purpose of the study is to explore patients’ perceptions, attitudes and beliefs about the safety practices utilized by nurses when administering medications. Specifically, the study addresses patients’ perceptions of nurse behaviours regarding safe medicine administration, patient behaviours, patients’ perceptions and nurse behaviours regarding pain medicine, patients’ perceptions of nursing care, and patients’ perceptions of their participation/accountability in care. The results identify key safety issues from a patients’ perspective to focus change strategies that will improve patient care. / x, 125 leaves ; 29 cm

Older people admitted to hospital are at high risk of rehospitalization and medication errors. We have demonstrated, in a randomized controlled trial, that a clinical pharmacist intervention reduces the incidence of revisits to hospital for patients aged 80 years or older admitted to an acute internal medicine ward. The aims of this thesis were to further study the effects of the intervention and to investigate possibilities of targeting the intervention by identifying predictors of treatment response or adverse health outcomes. The effect of the pharmacist intervention on the appropriateness of prescribing was assessed, by using three validated tools. This study showed that the quality of prescribing was improved for the patients in the intervention group but not for those in the control group. However, no association between the appropriateness of prescribing at discharge and revisits to hospital was observed. Subgroup analyses explored whether the clinical pharmacist intervention was equally effective in preventing emergency department visits in patients with few or many prescribed drugs and in those with different levels of inappropriate prescribing on admission. The intervention appeared to be most effective in patients taking fewer drugs, but the treatment effect was not altered by appropriateness of prescribing. The most relevant risk factors for rehospitalization and mortality were identified for the same study population, and a score for risk-estimation was constructed and internally validated (the 80+ score). Seven variables were selected. Impaired renal function, pulmonary disease, malignant disease, living in a nursing home, being prescribed an opioid and being prescribed a drug for peptic ulcer or gastroesophageal reflux disease were associated with an increased risk, while being prescribed an antidepressant drug (tricyclic antidepressants not included) was linked with a lower risk. These variables made up the components of the 80+ score. Pending external validation, this score has potential to aid identification of high-risk patients. The last study investigated the occurrence of prescription errors when patients with multi-dose dispensed (MDD) drugs were discharged from hospital. Twenty-five percent of the MDD orders contained at least one medication prescription error. Almost half of the errors were of moderate or major severity, with potential to cause increased health-care utilization.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / This study has as objectives: to analyze the perceptions of intensive care unit nursing professionals about the occurrence of safety incidents related to the medical therapy; to identify the factors that interfere positively and negatively for the occurrence of safety incidents related to the medical therapy; to know the strategies adopted by the intensive care unit nursing professionals for the prevention and control of safety incidents related to the medical therapy. Method: exploratory-descriptive research with a qualitative approach, carried out in a medium-sized hospital in the south of Brazil. The subjects were four nurses and eleven nursing technicians of an adult intensive care unit. The data collection occurred in February and March, 2014, through a semi-structured interview and afterwards these data were submitted to Thematic Analysis. Results and discussions: the information obtained with the participants was grouped together in three categories: a) perceptions of intensive care unit nursing professionals about the occurrence of safety incidents related to medical therapy; b) interfering factors which contribute for the occurrence of safety incidents related to the use of medications in intensive care; c) strategies adopted by nursing professionals for the reduction of safety incidents related to the use of medications in ICU. The interviewees reported having already heard about the topic, however showed uncertainties about the concepts of safety incidents, adverse events and medication errors. They mentioned having already experienced some situations involving safety incidents related to the medical therapy; the adopted action consists of the communication of the event to the nurse and the intensification of patient care, in order to minimize the consequences of the error and to promote the reestablishment of organic functions. The working routines, the complexity of the clinical status of patients, the care fragmentation, physical structure, the hurry, work overload, lack of recognition and lack of attention are some of the factors mentioned which contribute for the occurrence of incidents. However, the shift change, the attention, medical prescription and medication labels check and the patient identification the five medication rights are pointed out as human factors that can help minimize the occurrence of incidents. The medical prescription and medication labels check, the non-administration of medication in case of doubt, the adequate patient and medication identification were mentioned as strategies for the prevention of the occurrence of safety incidents. Conclusions: it was demonstrated the necessity of constant update by the professionals, as well as the definition of concepts and the standardization of procedures in case of safety incidents. Besides, it is utterly important the implementation of a system of voluntary notification in which the professional does not need to identify him/herself, and also the support and guidance by the nurse to the nursing technicians about the preparation and administration of the medication. These are a few of the actions which represent valuable tools for the improvement of care, thus promoting professionals‟ satisfaction and also promoting the culture of safety, rather than the punitive one. / Este estudo tem como Objetivos: analisar as percepções de profissionais de enfermagem atuantes em unidade de terapia intensiva sobre a ocorrência de incidentes de segurança relacionados à terapia medicamentosa; identificar os fatores que interferem para a ocorrência de incidentes de segurança relacionados à terapia medicamentosa; conhecer as estratégias adotadas pelos profissionais de enfermagem atuantes em unidade de terapia intensiva para a prevenção e controle dos incidentes de segurança relacionados à terapia medicamentosa. Método: pesquisa exploratório-descritiva com abordagem qualitativa, realizada em um hospital de médio porte do Sul do Brasil. Entrevistaram-se quatro enfermeiros e 11 técnicos de enfermagem da unidade de terapia intensiva adulto. A coleta de dados ocorreu nos meses de fevereiro e março de 2014, por meio de entrevista semiestruturada e os dados foram submetidos à Análise de Temática. Resultados e discussões: as informações obtidas junto aos participantes foram agrupadas em três categorias: a) percepções de trabalhadores de enfermagem atuantes em uma unidade de terapia intensiva, sobre a ocorrência de incidentes de segurança relacionados à terapia medicamentosa; b) fatores que interferem para a ocorrência de incidentes de segurança relacionados ao uso de medicamentos em terapia intensiva; c) estratégias adotadas pelos trabalhadores de enfermagem para redução dos incidentes de segurança relacionados ao uso de medicamentos em UTI. Os entrevistados já ouviram falar sobre o tema, porém demonstram incertezas quanto aos conceitos de incidente de segurança, evento adverso e erros de medicação. Citam que já vivenciaram alguma situação de incidentes de segurança com relação à terapia medicamentosa e a conduta adotada consiste na comunicação do evento ao enfermeiro e a intensificação dos cuidados ao paciente, a fim de minimizar as consequências do erro e promover o restabelecimento das funções orgânicas. As rotinas de trabalho, a complexidade do quadro clínico dos pacientes, a fragmentação do cuidado, a estrutura física, a pressa, a sobrecarga de trabalho, falta de reconhecimento e falta de atenção são alguns dos fatores citados que contribuem, para facilitar a ocorrência dos incidentes. No entanto, a passagem de plantão, a atenção, a conferência da prescrição médica e dos rótulos da medicação, a identificação do paciente e os cinco certos da medicação são apontados como fatores humanos que podem auxiliar para minimizar a ocorrência destes. A conferência da prescrição médica e dos rótulos da medicação, não administração de medicamentos em caso de dúvidas, identificação adequada do paciente e da medicação foram citadas como estratégias para a prevenção da ocorrência de incidentes de segurança. Conclusões: evidencia-se a necessidade de aperfeiçoamento constante dos trabalhadores, bem como a definição de conceitos e a uniformização das condutas diante dos incidentes de segurança. Além disso, é de fundamental importância a implantação de um sistema de notificação voluntária em que o profissional não necessite se identificar, além do acompanhamento e orientação por parte do enfermeiro aos técnicos de enfermagem quanto ao preparo e administração de medicamentos. Estas são algumas das ações que se constituem em valiosas ferramentas para a qualificação do cuidado, promovendo a satisfação dos trabalhadores e a cultura de segurança ao invés da cultura punitiva.

Made available in DSpace on 2014-12-17T14:13:51Z (GMT). No. of bitstreams: 1 RodrigoSD_DISSERT_partes.pdf: 44411 bytes, checksum: 62fe7b929c3d90fda22ce22c688f7e52 (MD5) Previous issue date: 2011-02-04 / Prescription errors are the most serious type of medication errors found in the health system. The main purpose of this study was to evaluate the quality of clonazepam prescriptions. A descriptive and observational study with retrospective data collection was conducted at 30 community pharmacies in Natal/RN, Brazil, after informed consent was obtained from the pharmacists. A sample of 313 prescription notifications was randomly collected in October 2009. They were analyzed for legible handwriting and completeness. During the study, one researcher, two pharmacists, and one pharmacy undergraduate student evaluated patient and purchaser identification, pharmaceutical form, dosing regimen, administration route, and prescription by generic name. This research was approved by the institutional Ethics Committee. Among the 313 collected notifications, only 44.1% were legible. A total of 55.91% (175/313) had at least one illegible item, 100% contained incomplete information, and 97.12% (304/313) contained one or more abbreviations. The proportion of illegible handwriting related to the patient s identification (p=0.0001) was statistically significantly greater than that related to the drug purchaser s identification (p=0.0004). Contrary to legal requirements, prescriptions with the generic name accounted for 13.42% (42/313) of the total. All the examined notifications were handwritten. Prescription errors, which potentially can have serious consequences, have been evaluated worldwide, although little is known about this subject as it relates to community pharmacies. This study showed high percentages of prescribing problems, which justifies the development of future research about medication errors in community pharmacies and education activities for prescribers / Os erros de prescri??o s?o os mais s?rios tipos de erros de medica??o encontrados no sistema de sa?de. Sendo assim, o principal objetivo desse estudo foi avaliar a qualidade das notifica??es de receita de clonazepam. Um estudo descritivo e observacional, com coleta retrospectiva de dados, foi conduzido em 30 farm?cias comunit?rias no munic?pio de Natal/RN, Brasil. Ap?s a obten??o do termo de consentimento livre e esclarecido por parte dos farmac?uticos comunit?rios, uma amostra de 313 notifica??es de receita de clonazepam foi aleatoriamente coletada em Outubro de 2009. As notifica??es foram analisadas quanto ? legibilidade e completude de informa??es. Durante o estudo, uma comiss?o, constitu?da por um dos pesquisadores, dois farmac?uticos e um estudante de gradua??o em farm?cia, avaliou os seguintes par?metros: identifica??o do paciente e comprador do medicamento, forma farmac?utica, posologia, via de administra??o e prescri??o pela denomina??o gen?rica. A pesquisa foi aprovada pelo Comit? de ?tica em pesquisa da Universidade Federal do Rio Grande do Norte. Dentre 313 notifica??es de receita de clonazepam coletadas, apenas 44,1% apresentaram-se leg?veis. Um total de 55,91% (175/313) demonstrou pelo menos um dado ileg?vel, 100% continham informa??es incompletas e 97,12% (304/313) possu?am uma ou mais abreviaturas. A propor??o de ilegibilidade relacionada ? caligrafia da identifica??o do paciente (p=0,0001) foi estatisticamente mais significante que a relacionada ? caligrafia da identifica??o do comprador do medicamento (p=0,0004). Contrariando dispositivos legais, a prescri??o pela denomina??o gen?rica ocorreu em apenas 13,42% (42/313) do total. Todas as notifica??es de receita examinadas estavam escritas ? m?o. Os erros de prescri??o, que potencialmente podem levar a s?rias consequ?ncias, t?m sido mundialmente estudados, embora pouco seja conhecido no ?mbito da farm?cia comunit?ria. Esse estudo mostrou elevados percentuais de problemas relacionados ? prescri??o, o que justifica o desenvolvimento de pesquisas futuras sobre erros de medica??o em farm?cias comunit?rias e de atividades de ensino para os prescritores

Submitted by Fabio Sobreira Campos da Costa (fabio.sobreira@ufpe.br) on 2016-05-09T13:14:39Z No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) TESE - ALOÍSIA PIMENTEL BARROS.pdf: 1927061 bytes, checksum: ab8816c302eba2f6832274e952f19f5f (MD5) / Made available in DSpace on 2016-05-09T13:14:39Z (GMT). No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) TESE - ALOÍSIA PIMENTEL BARROS.pdf: 1927061 bytes, checksum: ab8816c302eba2f6832274e952f19f5f (MD5) Previous issue date: 2015-09-30 / Erros de medicação consistem emqualquer evento evitável que pode levar ao uso inapropriado de medicamentos ou causar dano a um paciente, enquanto o medicamento está sob o controle dos profissionais de saúde, pacientes ou consumidores. Existem tipos de erros diferentes, porém, os mais comuns ocorrem durante o preparo e a administração de medicamentos que são procedimentos desempenhados pela enfermagem.Pesquisas mostram que entre as estratégias desenvolvidas para prevenir os erros, está a educação dos profissionais envolvidos no processo. Dessa forma delineou-se a presente pesquisa com o objetivo de analisar a trajetória de uma equipe de Enfermagem na busca de melhores práticas no preparo e administração de medicamentos em Unidade de Terapia Intensiva Neonatal e Pediátrica. Foi realizado um estudo de intervenção, na modalidade de pesquisa-ação, desenvolvido em quatro etapas, com profissionais de enfermagem, no período de agosto de 2014 a janeiro de 2015 em uma UTI neonatal e pediátrica de um Hospital do Sistema Único de Saúde na cidade de Recife-PE. Na 1ª etapa, com 40 participantes, foi realizado um diagnóstico inicial para conhecer, a partir da perspectiva dos profissionais, fatores que contribuem para erros no preparo e administração de medicamentos. Na 2ª etapa foi desenvolvida uma ação educativa com 12 participantes, através de um grupo operativo (GO),que após identificar os principais fatores que contribuem para erros no preparo e administração de medicamentos, definiu como estratégias para transformação da realidade: a criação de um núcleo de educação permanente no cenário do estudo, as medicações serem despachadas da farmácia identificadas no sistema de cores, ambiente iluminado e com balcão exclusivo para o preparo de medicamentos, implantação dos 9 certos do preparo e administração de medicamentos em forma de banner, implantação de prescrição eletrônica, identificação com placas nos leitos dos pacientes em uso de medicamentos potencialmente perigosos e montar protocolos de preparo e administração de algumas medicações. Na 3ª etapa ocorreu a implantação das estratégias propostas pelo GO no cenário do estudo. Na 4ª etapa foram elencados,através de entrevista semi-estruturada, os limites e possibilidades das estratégias implantadas. Participaram dessa etapa 40 profissionais de enfermagem. O material coletado na 1ª e 4ª etapas foram submetidos a técnica de análise de dados proposto por Bardin. Na 1ª etapa emergiram as categorias de análise: conceito de erros de medicação, fatores contribuintes para a ocorrência do erro e educação como ferramenta para melhores práticas no preparo e administração de medicamentos. Os dados dessa etapa subsidiaram a ação educativa no GO na 2ª etapa, a qual permitiu o desenvolvimento das estratégias que poderiam prevenir os erros no preparo e administração de medicamentos. Na 4ª etapa ao serem elencados os limites e possibilidades das estratégias implantadas, cinco categorias emergiram: o fazer da equipe de enfermagem no preparo e administração de medicamentos em UTI neonatal e pediátrica, a rotina/prática não reflexiva como fator contribuinte para o erro de medicação, competências e habilidades mobilizados para o preparo e administração de medicamentos, ação educativa e as mudanças na prática do preparo e administração de medicamentos, limites identificados na ação educativa. Dessa forma, um processo de mudança foi iniciado e os participantes envolvidos comprovaram ser possível transformar a realidade quando a isso se propõem. A participação na ação educativa instrumentalizou-os para uma avaliação crítica no serviço, evidenciando um resultado positivo da intervenção. / Medication error is any preventable event that may lead to inappropriate medication use or harm to a patient while the medicine is under the control of health professionals, patients or consumers. There are different types of errors, however, the most common occur during the preparation and administration of medications that are procedures performed by nurses. Research shows that among the strategies developed to prevent errors, is the education of professionals involved in the process. Thus it is outlined this research in order to analyze the trajectory of a nursing team in the search for best practices in the preparation and administration of drugs in the Intensive Care Unit Neonatal and Pediatric. Thus it is outlined this research in order to analyze the trajectory of a nursing team in the search for best practices in the preparation and administration of drugs in the Intensive Care Unit Neonatal and Pediatric. An intervention study was conducted in the form of action research, developed in four stages, with nursing professionals, in August 2014 to January 2015 in a neonatal and pediatric ICU of a Unified Health System Hospital in the city Recife-PE.In Step 1, with 40 participants, was held an initial diagnosis to know, from the perspective of professionals, factors that contribute to errors in the preparation and administration of medications. In the 2nd stage an educational activity with 12 participants was developed through an operative group (GO), that after identifying the main factors that contribute to errors in the preparation and administration of medicines, defined as strategies to transform reality: the creation of a core of permanent education in the study setting, medications are shipped from the pharmacy identified in the color system, lit environment with unique counter for medication preparation, implementation of 9 certain preparation and administration of medications in the form of banner, deployment electronic prescribing, identification plates the beds of patients on high-alert medications and assemble preparation protocols and administration of some medications. In the 3rd step was the implementation of the strategies proposed by the GO in the study setting. In the 4th stage were listed through semi-structured interview, the limits and possibilities of implemented strategies. Participated in this stage 40 nursing professionals. The material collected in the 1st and 4th stages were subjected to data analysis technique proposed by Bardin. In the 1st stage emerged the categories of analysis: concept of medication errors, contributing factors to the occurrence of the error and education as a tool for best practices in the preparation and administration of medications. The data that stage supported the educational activities in the GO in the 2nd step, which enabled the development of strategies that could prevent mistakes in the preparation and administration of medications. In the 4th stage to be listed the limits and possibilities of implemented strategies, five categories emerged: the making of the nursing staff in the preparation and administration of medicines in NICU and pediatric, routine / non reflective practice as a contributing factor to medication errors , skills and abilities mobilized for the preparation and administration of medicines, educational activity and changes in the practice of preparation and administration of medications, limits identified in the educational activity. Thus, a process of change has started and participants involved proved to be possible to transform reality when it proposed. Participation in educational activities instrumentalized them to a critical evaluation in the service, showing a positive result of the intervention.