Eventos adversos aos medicamentos e erros de medicação são muito comuns na prática assistencial e podem ocorrer em qualquer etapa do processo da terapia medicamentosa, contribuindo com a ocorrência de iatrogenias nos pacientes devido ao uso incorreto dos medicamentos ou a sua omissão. Neste contexto, encontramse as prescrições médicas que têm papel ímpar na prevenção do erro, uma vez que prescrições ambíguas, ilegíveis ou incompletas podem contribuir com a ocorrência destes eventos. Esta investigação teve o propósito de analisar a redação de prescrições médicas em unidades de clínica médica de cinco hospitais Brasileiros, comparar os dados obtidos entre os hospitais e propor recomendações para a prevenção de futuros erros de medicação. Tratou-se de um estudo descritivo que utilizou de dados secundários obtidos de uma pesquisa multicêntrica realizada em 2005. A população foi composta por 1.425 medicamentos administrados em discordância com a prescrição. Deste total, a administração de medicamentos em horário diferente do prescrito foi o mais freqüente nos cinco hospitais investigados, correspondendo a 76,0%. A análise da redação da prescrição revelou que 93,6% continham siglas e/ou abreviaturas, 10,7% não apresentavam dados do paciente, 4,3% omitiram informações sobre o medicamento e 4,2% apresentavam alterações e/ou suspensão do medicamento. Com a implantação do sistema computadorizado de prescrições, associada à prática da educação continuada e permanente dos profissionais envolvidos no sistema de medicação será possível minimizar os danos causados aos pacientes hospitalizados decorrentes da administração de medicamentos e, consequentemente, melhorar a qualidade do cuidado prestado. / Adverse events related to medicines and medication errors are very common in the health care assistance and can occur at any stage of the medication process, contributing with the occurrence of iatrogenys in the patients due to the incorrect use of medicines or its omission. In this context, we find medical orders which has uneven role in the prevention of medication error, once ambiguous, unreadable or incomplete medication order may contribute with the occurrence of these events. This study had the intention to analyze the writing of medical orders at internal medicine units of five Brazilian hospitals, to compare data between these hospitals and to consider recommendations for the prevention of future medication errors. This descriptive study used secondary data from a multicentric research occurred in 2005. The population was composed of 1.425 medications given in discordance with the medical order. From this total, the medication administration at different schedule administration time was the most frequent error found at the five hospitals investigated, corresponding to 76.0%. The analysis of the writing of the medical order disclosed that 93.6% contained acronyms and/or abbreviations, 10.7% did not present any information about the patient, 4.3% had omitted information about the medicine and 4.2% presented alterations and/or suspension of the medicine. With the implantation of the computerized prescription order entry system, associate to the practice of continued and permanent education of the involved professionals in the system of medication it will be possible to minimize the damage caused to the patients in the hospital deriving from the administration of medicine and, therefore, improve the quality of the care given.

O método da análise de causa raiz tem sido utilizado para investigar e analisar erros de medicação, promover a segurança do paciente e implementar o sistema de forma a garantir a qualidade na assistência e, por isso, ele foi utilizado neste estudo. Os objetivos do estudo foram descrever as doses de medicamentos preparadas e administradas diferentemente daquelas prescritas, em uma clínica médica, de um hospital universitário, utilizando o método da análise de causa raiz; apresentar a freqüência dos tipos de erros identificados, dos turnos de ocorrência, dos profissionais e dos medicamentos envolvidos; elaborar um desenho dos fatores causais de cada dose observada e propor estratégias e recomendações que evitem a recorrência desses erros no sistema de medicação. Tratou-se de estudo descritivo e que realizou uma análise secundária de dados de um estudo já existente. No estudo, 74 erros de medicação foram identificados durante o preparo e a administração de medicamentos pela equipe de enfermagem, sendo que 84,3% foram cometidos por auxiliares de enfermagem que prepararam ou administraram os medicamentos. Erros de dose (24,3%), erros de horário (22,9%) e medicamentos não autorizados (13,5%) foram os mais freqüentes. Dos 70 eventos descritos, a equipe de enfermagem utilizou a requisição da farmácia para preparar os medicamentos em 81,4% das observações, rotulou os medicamentos inadequados ou não rotulou em 80%, não consultou a prescrição médica antes da administração em 74,3% dos eventos, não orientou (41,4%) e não confirmou o paciente pelo nome antes da administração em 22,9% dos eventos. Além desses fatores, outros, como falta de equipamento no setor, medicamento deixado com o acompanhante para administrar, comunicação inadequada e alteração da prescrição médica contribuíram para a ocorrência dos erros. Assim, erros de medicação foram identificados, a análise de causa raiz foi realizada identificando múltiplos fatores que contribuíram para a ocorrência dos erros e estratégias foram recomendadas para evitar a ocorrência dos erros. Este estudo contribuiu para a garantia da segurança do paciente, apresentando o método de análise de erros e as estratégias que podem ser utilizadas pelas instituições para a prevenção dos erros. / Root cause analysis has been used to investigate and analyzing medication errors, promoting patient safety and system improvement, for that, he was used in this study. This study aimed at: describing, by using the root cause analysis method, medication doses prepared and administered differently from those prescribed at a medical clinical of a university hospital; presenting the frequency of the identified error types, shifts of occurrence and professionals and drugs involved; outlining the causative factors for each dose and proposing strategies that will prevent the recurrence of such errors in the medication system. It is a descriptive study in which a secondary analysis of data from a previously existing investigation was performed. In the study, 74 medication errors were identified during medication preparation and administration by the nursing staff, of whose members 84.3% were nursing auxiliaries who prepared or administered medication. Dose errors (24.3%), schedule errors (22.9%) and unauthorized medication (13.5%) were the most frequent. Of the 70 events described, the nursing staff used the pharmacy order to prepare the medication in 81.4% of the observations, labeled inadequate medication or did not in 80%, did not consult the medical order prior to administration in 74.3% of the events, did not provide patient orientation (41.4%) and did not confirm the patient\'s name prior to administration in 22.9% of events. Additionally to these factors, others such as the lack of equipment in the facilities, medication being left for the patient\'s companion to administrate, inadequate communication and alteration of the medical order contributed to error occurrence. Hence, medication errors were identified, and root cause analysis was performed, leading to the identification of multiple factors that contributed to error occurrence, and strategies were recommended in order to prevent it. Therefore, this study has contributed to patient safety by presenting an analysis method and strategies that can be used by institutions for the prevention of errors.

Medication errors cause harm, yet most of them are preventable (Institute of Medicine, 2006). Nurses spend 40% of their time administering medications; therefore they play a key role in the reduction of medication errors. Little empirical evidence has been collected about the effectiveness of nursing education in reducing medication errors committed by nursing students. Traditional educational interventions focus on the five rights of medication administration; however, the literature shows that interventions focused on instilling a culture of safety have a greater impact on reducing medication errors. The purpose of this article is to review educational strategies that have been implemented and tested in pre-licensure nursing programs to reduce medication errors committed by nursing students.

Aim: The aim of this study was to examine if student nurse participation in root cause analysis has the potential to reduce harm to patients from medication errors by increasing student nurse sensitivity to signal and responder bias. Background: Schools of nursing have traditionally relied on strategies that focus on individual characteristics and responsibility to prevent harm to patients. The modern patient safety movement encourages utilization of systems theory strategies like Root Cause Analysis (RCA). The Patient Risk Detection Theory (Despins, Scott-Cawiezell, & Rouder, 2010) supports the use of nurse training to reduce harm to patients. Method. Descriptive and inferential analyses of the demographic and major study variables were conducted. Validity and reliability assessments for the instruments were performed. The Safe Administration of Medications-Revised Scale (Bravo, 2014) was used to measure sensitivity to signal. The Safety Attitudes Questionnaire (SAQ; Sexton et al., 2006) was used to assess responder bias; this was the first use of this instrument with nursing students. Results: The sample consisted of 125 senior-level nursing students from three universities in the southeastern United States. The SAQ was found to be a valid and reliable test of safety attitudes in nursing students. Further support for the validity and reliability of the SAM-R was provided. A significant difference in safety climate between schools was observed. There were no differences detected between the variables. Conclusion: The results of this study provide support for the use of the SAQ and the SAM-R to further test the PRDT, and to explore methods to improve nursing student ability to administer medications safely.

Problem: Interruption during medication administration is a significant patient safety concern within health care, especially during the administration of high risk medications in nursing. Patient-controlled analgesia (PCA) devices are frequently associated with adverse events and have a four-fold increased risk of patient injury compared to non-PCA related adverse events. While the nature and frequency of interruptions have been established for nurses* medication processes, the impact of interruption frequency on nurses* PCA interaction has not been fully measured or described. Purpose: The purposes of this study were to quantify the impact of interruption frequency on registered nurses* (RN) performance, satisfaction, and cognitive workload during PCA interaction, and to determine nurses* perceptions of the impact of interruption frequency. Methods: This study employed a mixed-method design. First, an experimental repeated measures design was used to quantify the impact of interruption frequency on a purposive sample of nine medical-surgical RNs. The RNs completed PCA programming tasks in a simulated laboratory nursing environment for each of four conditions where interruption frequency was pre-determined. Four established human factors usability measures were completed for each of the four test conditions. The research questions were answered using repeated measures analysis of variance with (RM-ANOVA), McNamar*s test, and Friedman*s test. After each experiment, semi-structured interviews were used to collect data that were analyzed using inductive qualitative content analysis to determine RNs* perceptions of the impact of interruption frequency. Results: Results of the RM-ANOVA were significant for the main effect of interruption frequency on efficiency F(3,24)=9.592, p = .000. McNemar*s test did not show significance for the impact of interruption frequency on effectiveness (accuracy). Friedman test showed participant satisfaction was significantly impacted by interruption frequency (x2=9.47, df=3, p=0.024). Friedman test showed no significance for the main effect of interruption frequency on cognitive workload scores by condition type (x2=1.88, df=3, p=0.599). Results of the qualitative content analysis revealed two main categories to describe nurses* perception of interruption frequency: the nature of interruptions and nurses* reaction to the interrupted work environment. Discussion/Implications: The results suggested that interruption frequency significantly affected task completion time and satisfaction for participants but not participant accuracy or cognitive workload. A high error rate during PCA programming tasks indicated the need to evaluate the conditions in which RNs complete PCA programming as each error presents potential risk of patient harm. RNs* described the impact of interruption frequency as having a negative impact on the work environment and subsequently implement compensating strategies to counterbalance interruptions. RNs* perceived that patient safety was negatively impacted by frequent interruption. RNs experienced negative intrapersonal consequences as a results of frequent interruption. Additional study is needed to better understand the impact of interruption frequency on RNs* performance accuracy and cognitive workload.

Yes / Introduction: The complex healthcare system that provides patients with medicines places them at risk when care is transferred between healthcare organisations, for example discharge from hospital. Consequently, under-standing and improving medicines management, particularly at care transfers, is a priority.Objectives: This study aimed to explore the medicines management system as patients experience it and determine differences in the patient-perceived importance of people in the system.Methods: We used a Social Network Analysis framework, collecting ego-net data about the importance of people patients had contact with concerning their medicines after hospital discharge. Single- and multi-level logistic regression models of patients' networks were constructed, and model residuals were explored at the patient level.This enabled us to identify patients' networks with support tie patterns different from the general patterns suggested by the model results. Qualitative data for those patients were then analysed to understand their differing experiences.Results: Networks comprised clinical and administrative healthcare staff and friends and family members.Networks were highly individual and the perceived importance of alters varied both within and between patients. Ties to spouses were significantly more likely to be rated as highly important and ties to community pharmacy staff (other than pharmacists) and to GP receptionists were less likely to be highly rated. Patients with low-value medicines management networks described having limited information about their medicines and alack of understanding or help. Patients with high-value networks described appreciating support and having confidence in staff.Conclusions: Patients experienced medicines management as individual systems within which they interacted with healthcare staff and informal support to manage their treatment. Multilevel models indicated that there are unexplained variables impacting on patients' assessments of their medicines management networks. Qualitative exploration of the model residuals can offer an understanding of networks that do not have the typical range of support ties. / National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC)

This thesis evaluated the effects of two types of training on nurses’ ability to safely and efficiently administer IV medications using a smart infusion pump. A high fidelity simulated nursing unit was created in which nurses recruited from the University Health Network programmed a series of infusions after receiving training. A training script modeled after the pump vendor’s training sessions was created and tested first on 24 nurses. The results were analyzed for deficiencies in safety and efficiency from a human factors and education perspective and a new training script was created and tested on a group of 23 nurses. No significant differences were found between training groups on measures related to safety, but significant differences were found in nurse efficiency and behaviour in some aspects of pump programming. This study sets a precedent for human factors evaluation being used in tandem with existing training practices and lays the groundwork for further exploration on this topic.

This thesis evaluated the effects of two types of training on nurses’ ability to safely and efficiently administer IV medications using a smart infusion pump. A high fidelity simulated nursing unit was created in which nurses recruited from the University Health Network programmed a series of infusions after receiving training. A training script modeled after the pump vendor’s training sessions was created and tested first on 24 nurses. The results were analyzed for deficiencies in safety and efficiency from a human factors and education perspective and a new training script was created and tested on a group of 23 nurses. No significant differences were found between training groups on measures related to safety, but significant differences were found in nurse efficiency and behaviour in some aspects of pump programming. This study sets a precedent for human factors evaluation being used in tandem with existing training practices and lays the groundwork for further exploration on this topic.

Current status: Currently, the safety of patients is a key element in the provision of safe and high quality care. The drug administration is the main danger fro the patiens which is neccessery to be mentined. (Buchini and Quattrin, 2012). Each provider of health care services should follow specific internal regulation of medication process. Morover, it is necessary to support employee to report possible misconduct in the adverse event to the reporting system, which is used to create functional corrective measures. However, we have to realize that it is impossible to forget the role of the patient in the prevention of medication errors. Goals: The main aim of the research was to find out whether the nurses know the recommended nursing procedure of medication to patients.Not only, mentioned the most common misconduct during the administration of drugs, but also identify the most common causes of these misconductions. After that to describe preventive mechanisms for reducing the risk of medication errors. In conclusion it was necessary to point out the cooperation of patients in the process of safe medication administration. Methodology: The research was conducted using a qualitative research method. The data were collected the polling method, along with in-depth interview technique. The qualitative data was coded using ,,paper and pencil" and semantically organized into groups along with the categorization schemes. Research file: In order to archieve the highest level of objectivity the research was carried out with a group of nurses and patients only from the Surgical Department of a particular nursing unit. First, the research consisted of six nurses working in the surgical Department at the hospital České Budějovice a.s. and the second research file consisted of six clients admitted to the same Department. Due to the fact that the respondents were genrally reluctant to cooperate the researched sample is limited.

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