Orientador: César Tadeu Spadella / Coorientador: Silvana Andrea Molina Lima / Banca: Wilza Carla Spiri / Banca: Juang Horng Jyh / Resumo: Os erros de medicação têm sido considerados um dos mais comuns tipos de erros que ocorrem em hospitais, tendo papel relevante no aumento das taxas de morbidade e mortalidade e nos custos do sistema de saúde. Por estas razões, é imperativa a adoção de estratégias que permitam reduzir os erros de medicação e aumentar a qualidade e a segurança dos cuidados prestados à saúde dos pacientes hospitalizados. Este artigo visa a apresentar uma análise crítica dos principais resultados de pesquisa sobre os erros de medicação dentro das instituições de saúde, esperando contribuir para o melhor conhecimento do problema e a tomada das iniciativas necessárias para preveni-los. Foram pesquisadas as bases de dados do Cumulative Index to Nursing & Allied Health (CINAH), PubMed, Web of Knowledge, Scopus e Science Direct, no período compreendido entre 1990 a 2013, usando as palavras-chaves: erros de medicação, administração de medicamentos, cuidados à saúde, cuidados de enfermagem e eventos adversos. Os estudos mostram que embora a falha humana seja importante de ser investigada, a análise do contexto no qual o erro de medicação ocorreu é uma das questões-chave na abordagem do erro em saúde, pois, em geral, um erro de medicação, está muito mais ligado às deficiências ou inadequações do ambiente físico e/ou a falhas dos processos organizacionais e psicossociais do sistema de saúde, do que propriamente na falha do indivíduo. Entre os fatores de risco para os erros de medicação, relacionados a variáveis ambientais estão incluídos: inexistência/deficiência de instalações ou inadequado uso do espaço, desorganização da estocagem de medicamentos, inexistência/inadequação de equipamentos, e iluminação imprópria e/ou excesso de ruídos no ambiente de trabalho. Entre os fatores de risco de origem organizacional e psicossocial estão incluídos: deficiências de recursos humanos, sobrecarga de trabalho, desvios de ... / Abstract: Not available / Mestre

O objeto de estudo é o preparo e a administração de medicamentos pela enfermagem por via intravenosa. O objetivo geral foi discutir as consequências, para os pacientes, dos erros encontrados a partir do preparo e da administração de medicações de uso intravenoso pela enfermagem, no ambiente hospitalar. Os objetivos específicos foram determinar os grupos medicamentosos e os medicamentos envolvidos em erros; e identificar o tipo e frequência desses erros que ocorrem no preparo e administração de medicamentos intravenosos pela enfermagem. Trata-se de uma pesquisa com desenho transversal de natureza observacional, sem modelo de intervenção. Foi desenvolvida em um hospital público, da rede sentinela, do Rio de Janeiro onde foram observados técnicos de enfermagem preparando e administrando medicamentos intravenosos, em três setores: Unidade de Terapia Intensiva, Clínica Médica e Clínica Cirúrgica. Foram observadas 367 doses preparadas e 365 doses administradas, totalizado 732 doses, à luz de 14 categorias. Para cada dose observada havia somente duas possibilidades: certo ou errado. Com relação ao perfil das medicações, os grupos prevalentes foram os antimicrobianos com 176 doses (24,04%), seguidos dos antissecretores com 149 doses (20,36%) e analgésicos com 126 doses (17,21%). Anestésicos e anticonvulsivantes foram os menos observados. Todas as categorias foram divididas em dois grupos: os com potencial de dano para o paciente e os com potencial para alterar a resposta terapêutica do medicamento. Na etapa do preparo, no grupo com potencial de dano, as categorias foram: não troca as agulhas com 88,77% de erro; não desinfecção de ampolas (80,27%) e não faz limpeza de bancada (77,26%). Nas categorias não usa máscara e não identifica o medicamento, não foram encontrado erros. Para o grupo com potencial para alterar a resposta terapêutica, as categorias foram: hora errada (57,26%) e dose errada (6,58%). Na etapa da administração, no grupo com potencial de dano ao paciente, as categorias foram: não confere o medicamento com 96,73% de erro, não avalia flebite (87,47%), não avalia a permeabilidade (86,38%) e não confere o paciente (70,57%). Para o grupo com potencial para alterar a resposta terapêutica, a categoria hora errada apresentou 69,75% de erro; em dose errada e via errada não foi evidenciado erro. Percebeu-se que, nas duas etapas, o grupo prevalente foi o com potencial de dano paciente. Porém, no grupo com potencial para alterar o resultado terapêutico do medicamento, a categoria a hora errada foi a que, provavelmente, apresentou maiores prejuízos para o paciente. Considerando-se que o preparo e administração de medicamentos são umas das maiores responsabilidades da enfermagem e que os erros podem causar danos aos pacientes, sugere-se repensar o processo de trabalho da enfermagem e investir mais em questões que envolvam a segurança com a terapia medicamentosa. / The overall objective was to discuss the consequences for patients about the found errors from the intravenous medications preparation and administration by nurses in the hospital. The specific objectives were to determine the errors referring to involved drugs, their groups, type, and frequency in the intravenous medications preparation and administration by nurses. This is a survey of cross-sectional observational, without intervention model. It was developed in a public hospital, belonging to the sentinel network of Rio de Janeiro, where nursing technician were observed, preparing and administering intravenous medicines in three sectors: the Intensive Care Unit, Medical Clinic, and Surgical Clinic. There were observed 367 prepared doses and 365 administered, totaling 732 in the light of 14 categories. For each observed dose, there were only two possibilities, right or wrong. Regarding to the medication profile, the prevalent groups were antimicrobials with 176 doses (24.04%), followed by antisecretory medicines with 149 doses (20.36%), and analgesics with 126 doses (17.21%). Anesthetics and anticonvulsants were the least observed. All categories were divided into two groups: those with damage potential to the patient and others with potential to alter the drug therapeutic response. In the preparation stage, in the group with the damage potential, the categories were "do not exchange needles" with 88.77% of error, "no disinfection of ampoules (80.27%), and "do not clean bench" (77.26%). In the categories "not wearing a mask" and "do not identify the drug, no errors were found. For the group with potential to alter the therapeutic response, the categories were "wrong time" (57.26%) and "wrong dose" (6.58%). In the administration phase, in the group with damage potential to the patient, the categories were "do not confer the drug", with 96.73% of error, "do not evaluate phlebitis (87.47%), "do not measure permeability (86.38%) and "do not check the patient" (70.57%). For the group with potential to alter the therapeutic response, the categories "wrong time" had 69.75% of error; in "wrong dose and "wrong way" no errors were evidenced. It was noticed that in both steps the group with potential harm to the patient prevailed. However, in the group with potential to alter the medication therapeutic efficacy, the category wrong time was probably the one causing more damage to the patient. Considering that the medications preparation and administration are one of the nursing biggest responsibilities, and the errors can cause damage to patients, it is suggested rethinking nursing work process and investing more on issues involving the safety of drug therapy.

Introdução: Erros envolvendo medicamentos ocorrem frequentemente em hospitais, possuem natureza multidisciplinar e podem ocorrer nas várias etapas da terapia medicamentosa. Objetivos: Avaliar a seriedade, o tipo e os medicamentos envolvidos nos erros de medicação notificados no Hospital de Clínicas de Porto Alegre. Verificar a qualidade do conteúdo das notificações obtidas pelos instrumentos de notificação disponíveis na Instituição. Classificar os erros através de árvore de decisão para atos inseguros, quando aplicável. Métodos: Foram analisadas notificações comunicadas por escrito em 2010-2011. A amostra foi composta por 165 notificações. Os erros identificados foram classificados de acordo com a seriedade, o tipo e a classe farmacológica. Foram analisadas 114 notificações, nas quais um erro de fato ocorreu, quanto à qualidade das informações contidas. A qualidade foi avaliada considerando-se os itens preconizados pela ANVISA. A árvore de decisão para atos inseguros foi utilizada para verificar fatores individuais ou sistêmicos nos erros notificados. Resultados: Apesar de um maior número de notificações comunicadas em 2011, comparativamente a 2010, não houve uma alteração significativa no perfil de seriedade destes eventos. Os erros ocorridos ao longo do processo geraram, em algumas situações, novos erros de medicação associados. O tipo de erro mais frequente foi o de prescrição (40%). Nas 114 notificações de erro foram citados 122 medicamentos. O conteúdo das notificações demonstrou que todos itens preconizados pela ANVISA estavam presentes, mas informados em frequências diferentes. A caracterização dos atos inseguros foi realizada com as 30 notificações comunicadas por ficha padronizada pela Instituição. Constatou-se que 19 ações se enquadram como possíveis violações por imprudência e 9 ações, como erros induzidos pelo sistema. Conclusão: A segurança dos pacientes depende do processo de comunicação, do registro adequado das informações e do monitoramento propriamente dito no uso dos medicamentos. / Background: Errors involving medications occur frequently in hospitals, they are multidisciplinary and can occur at many stages of drug therapy. Objectives: Assess the seriousness, the type and drugs involved in medication errors reported on Hospital de Clínicas de Porto Alegre. Checking the quality of the reports obtained by the notification tools available in the institution. Classifying errors by decision tree for unsafe acts, when applicable. Methods: The sample consisted of 165 notifications. The errors identified were classified according to the seriousness, type and pharmacological class. We analyzed 114 notifications, in which an error has occurred, as to the quality of information. The quality was evaluated considering the items recommended by ANVISA. The decision tree for unsafe acts was used to identify individual or systemic factors in the errors reported. Results: Although a greater number of notifications reported in 2011 compared to 2010, there was no significant change in the profile of seriousness of these events. The errors occurred during the process, have in some situations, new medication errors associated with it. The most common type of error is the prescription error (40%). In 114 reports, 122 medication errors were cited. The content of notifications showed that all items recommended by ANVISA were present, but reported at different frequencies. The characterization of unsafe acts were performed with 30 notifications from a standardized form by the institution. We verified that 19 actions were classified as potential violations recklessness and 9 actions, such as errors induced by the system. Conclusion: Patient safety depends on the communication process, the suitable recording of information and monitoring the appropiate use of medicines.

Introdução: Erros envolvendo medicamentos ocorrem frequentemente em hospitais, possuem natureza multidisciplinar e podem ocorrer nas várias etapas da terapia medicamentosa. Objetivos: Avaliar a seriedade, o tipo e os medicamentos envolvidos nos erros de medicação notificados no Hospital de Clínicas de Porto Alegre. Verificar a qualidade do conteúdo das notificações obtidas pelos instrumentos de notificação disponíveis na Instituição. Classificar os erros através de árvore de decisão para atos inseguros, quando aplicável. Métodos: Foram analisadas notificações comunicadas por escrito em 2010-2011. A amostra foi composta por 165 notificações. Os erros identificados foram classificados de acordo com a seriedade, o tipo e a classe farmacológica. Foram analisadas 114 notificações, nas quais um erro de fato ocorreu, quanto à qualidade das informações contidas. A qualidade foi avaliada considerando-se os itens preconizados pela ANVISA. A árvore de decisão para atos inseguros foi utilizada para verificar fatores individuais ou sistêmicos nos erros notificados. Resultados: Apesar de um maior número de notificações comunicadas em 2011, comparativamente a 2010, não houve uma alteração significativa no perfil de seriedade destes eventos. Os erros ocorridos ao longo do processo geraram, em algumas situações, novos erros de medicação associados. O tipo de erro mais frequente foi o de prescrição (40%). Nas 114 notificações de erro foram citados 122 medicamentos. O conteúdo das notificações demonstrou que todos itens preconizados pela ANVISA estavam presentes, mas informados em frequências diferentes. A caracterização dos atos inseguros foi realizada com as 30 notificações comunicadas por ficha padronizada pela Instituição. Constatou-se que 19 ações se enquadram como possíveis violações por imprudência e 9 ações, como erros induzidos pelo sistema. Conclusão: A segurança dos pacientes depende do processo de comunicação, do registro adequado das informações e do monitoramento propriamente dito no uso dos medicamentos. / Background: Errors involving medications occur frequently in hospitals, they are multidisciplinary and can occur at many stages of drug therapy. Objectives: Assess the seriousness, the type and drugs involved in medication errors reported on Hospital de Clínicas de Porto Alegre. Checking the quality of the reports obtained by the notification tools available in the institution. Classifying errors by decision tree for unsafe acts, when applicable. Methods: The sample consisted of 165 notifications. The errors identified were classified according to the seriousness, type and pharmacological class. We analyzed 114 notifications, in which an error has occurred, as to the quality of information. The quality was evaluated considering the items recommended by ANVISA. The decision tree for unsafe acts was used to identify individual or systemic factors in the errors reported. Results: Although a greater number of notifications reported in 2011 compared to 2010, there was no significant change in the profile of seriousness of these events. The errors occurred during the process, have in some situations, new medication errors associated with it. The most common type of error is the prescription error (40%). In 114 reports, 122 medication errors were cited. The content of notifications showed that all items recommended by ANVISA were present, but reported at different frequencies. The characterization of unsafe acts were performed with 30 notifications from a standardized form by the institution. We verified that 19 actions were classified as potential violations recklessness and 9 actions, such as errors induced by the system. Conclusion: Patient safety depends on the communication process, the suitable recording of information and monitoring the appropiate use of medicines.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Os Erros de MedicaÃÃo (EM) sÃo um importante desafio a ser superado na promoÃÃo do uso racional de medicamentos, fator contribuinte para o desenvolvimento de serviÃos de saÃde eficazes e seguros para os pacientes. EM podem ocorrer em vÃrias etapas da cadeia de utilizaÃÃo de medicamentos. No Brasil, pouco se conhece sobre o perfil dos erros e sobre a seguranÃa do processo de prescriÃÃo. Baseado na abordagem sistÃmica do erro foi realizado um estudo exploratÃrio, com determinaÃÃo da taxa de prevalÃncia de erros de prescriÃÃo clinicamente significativos (TPEPCS) e da taxa de seguranÃa do processo de prescriÃÃo de medicamentos (TSPPM) nas unidades de Cardiologia, Pneumologia e Pediatria de um hospital de referÃncia do CearÃ. No perÃodo de 20 de agosto a 03 de setembro de 2007, em dias alternados, foram analisadas 140 prescriÃÃes mÃdicas (PM), totalizando 1017 itens contendo medicamentos. A maioria das PM (75% - n=105) foram recebidas pelo serviÃo de farmÃcia no turno da tarde, 61,4% (n=86) pertencia a pacientes do sexo masculino e 22,2% (n=31) pertencia a pacientes com idade de 60 a 69 anos. No prontuÃrio dos pacientes das PM selecionadas, nÃo houve relato de alergia a medicamentos em 83,6% (n=117), nem registro do peso em 60% (n=84). Quanto aos componentes legais da prescriÃÃo, houve ausÃncia do registro do nÃmero do prontuÃrio em 63,3% (n=89), da unidade de internaÃÃo em 59,3% (n=83), do carimbo do prescritor em 28,6% (n=40) e da assinatura do mÃdico em 15% (n=21). Foram identificadas interaÃÃo medicamento-medicamento em 28,6% (n=40) das PM, interaÃÃo medicamento-alimento em 14,3% (n=20) e erros de prescriÃÃo clinicamente significativos (EPCS) em 25,9%, (n=30) sendo o mais recorrente a detecÃÃo de interaÃÃo medicamentosa potencialmente significante (26,61% - n=95). Boa parte dos medicamentos envolvidos nos EPCS (63,3% - n=201) pertenceu a classe terapÃutica de medicamentos cardiovasculares e houve a suspeita de ReaÃÃo Adversa a Medicamentos em apenas 1,8% (n=18) dos medicamentos prescritos. A denominaÃÃo mais utilizada na prescriÃÃo dos medicamentos foi a genÃrica (60,2% - n=612) e a concentraÃÃo nÃo foi prescrita em 56,4% (n=574) dos itens contendo medicamentos. Foi prescrito o diluente em 35,1% (n=65) dos medicamentos classificados como injetÃveis, enquanto nÃo foi prescrita a velocidade de infusÃo em 59,3% (n=121) dos injetÃveis e soluÃÃo para hidrataÃÃo. TambÃm foram prescritas informaÃÃes adicionais em 14,7% (n=150) dos itens contendo medicamentos e utilizadas abreviaturas em 97,6% (n=993) destes, sendo mais comum a abreviatura da via de administraÃÃo (36% - n=833). Ao final, foram calculadas a TPEPCS (35,10%) e TSPPM (64,9%), indicando a necessidade da reavaliaÃÃo do processo de prescriÃÃo e implementaÃÃo das estratÃgias educacionais. Portanto, a identificaÃÃo da taxas referidas constitui o primeiro passo na busca da prevenÃÃo de erros. PorÃm, para que ela possa estabelecer-se no Ãmbito hospitalar, sem propiciar um ambiente de puniÃÃes, faz-se necessÃrio que a responsabilidade pela seguranÃa do paciente seja vista como coletiva e que a abordagem sistÃmica do erro seja aplicada cotidianamente. / Medication errors are a great challenge to the rational use of drugs, which is a significant contributing factor to the development of effective and safe health assistance services to patients. Medication errors can occur at various stages in the drug use process. In Brazil, little is known about the profile of errors and the prescription process safety. In order to determine the prevalence rate of errors in prescribing clinically significant drugs (PREPCS) and the safety rate on prescription drug procedures (SRPDP), an exploratory study based on an approach in systematic error estimation was carried out at Cardiology, Pneumology and Pediatrics Units of a reference hospital in the State of CearÃ. From August 20 to September 3, 2007, on alternate days, 140 medical prescription â totaling 1,017 items containing drugs â were analyzed. Most medical prescriptions (75% - n=105) were received by the department of pharmacy in the afternoon shift; 61.4% (n=86) had been given to male patients and 22.2% (n=31) had been given to patients between 60 to 69 years of age. In 83.6% (n=117) of records of patients to whom the selected medical prescriptions had been given, no allergy to drugs were reported, and in 60% (n=84) of them the patientsâ weight was not informed. In regard to the legal components of the prescriptions, the patient record number was not informed in 63.3% (n=89) prescriptions; the hospital unit was not informed in 59.3% (n=83) prescriptions; the prescriberâs stamp was not stamped in 28.6% (n=40) prescriptions; and 15% (n=21) prescriptions had not been signed by the doctor. Drug-drug interactions were identified in 28.6% (n=40) medical prescriptions; drug-food interactions were identified in 14.3% (n=20) medical prescriptions; and clinically significant prescription errors (CSEP) were found in 25.9% (n=30) medical prescriptions, and the detection of potentially significant drug interactions (26.61% - n=95) was the most recurrent. Most drugs involved in CSEP (63.3% - n=201) belonged to a therapeutic class of cardiovascular medicines and there was suspicion of Adverse Drug Reaction in only 1.8% (n=18) of the prescription drugs. Generic names were most commonly used in the medical prescriptions (60.2% - n=612); and the concentration was not prescribed in 56.4% (n=574) of items containing drugs. The dilluent was prescribed in 35.1% (n=65) of injection drugs, while no infusion speed and hydration solution were prescribed in 59.3% (n=121) of injection drugs. Additional information was prescribed in 14.7% (n=150) of the items containing drugs; and abbreviations were used in 97.6% (n=993) of them, and administration routes were the most common abbreviations used (36% - n =833). And finally, the PREPCS (35.10%) and SRPDP (64.9%) were ascertained, thus indicating the need to reevaluate the process of prescribing and implementing educational strategies. Therefore, the identification of the aforesaid rates is the first step to be taken in order to prevent errors. However, in order to use them at hospitals without creating a punishment environment, the responsibility for the patientâs safety must be collective and an approach in systematic error estimation must be made regularly.

Bakgrund: Läkemedel är den vanligaste behandlingsformen inom sjukvården och samtidigt det är det bästa och mest effektiva alternativet, så är användningen av läkemedel förenat med risker och bieffekter. Dessa bieffekter är en av de ledande anledningarna till dödsfall i de flesta länder. Upp till 60 % av läkemedelsrelaterade problem skulle kunna undvikas. Det kan vara ett fel som kommer att skada, eller har potential att skada patienten, även kallad undvikbar läkemedelsavvikelse, som kan förekomma i läkemedelskedjan. I SVerige avlider 3150 personer per år av sådana skador. Syfte: Syftet med studien är att beskriva de undvikbara läkemedelsavvikelser som har rapporterats inom Synergi i Landstinget i Östergötland under 2011. Metod: Genomgång av landstinget avvikelserapporteringssystem Synergi med rapporter relaterade till läkemedel. Utifrån beskrivningen i fritexten bedömdes det som det handlade om en undvikbar läkemedelsavvikelse. Resultat: Under 2011 inkom 2750 rapporter varav 2320 klassades som undvikbara läkemedelsavvikelser och 6,7 % (n=155) av dessa ledde till skador. En patient avled till följd av en undvikbar läkemedelsavvikelse. Den vanligaste typen av fel var brist i rutin (n=1255) och vanligaste konsekvensen var uteblivna doser (n=604). Warfarin var det läkemedel som förekom i flest rapporter (n=140), medan uteblivna/för låga doser av heparin ledde till flest allvarliga skador (n=3). Slutenvården stod för 52 % (n=1211) av alla rapporter och även 80 % (n=125) av skadorna. Slutsats: Bristande rutiner kan vara en vanlig orsak till läkemedelsavvikelser. Därför behöver den svenska sjukvården satsa på att förbättra och förenkla sina rutiner, både mellan avdelningar och enskilt för att förbättra patientsäkerheten. Den har kommit en bit på väg, men behöver tydligare riktlinjer och mer utbildning och information till både avdelningar och de enskilda personer som arbetar inom sjukvården. / Background: Drugs are the most common way to treat illnesses in healthcare and the best and most efficient alternative. At the same time you must keep i mind that the use of drugs is always associated with risks and side effects. These side effects or adverse drug reactions are among the leading causes of death in many countries. At least 60 % of adverse drug reactions are preventable. A preventable drug reation is called a medication error. A medication error occurs when a failure in the treatment leads to harm to the patient, or has the potential to lead to harm to the patient. The treatment process is a chain of several events, from the diagnosis of an illness and the choice of drugs, to monitoring the administration. There are many steps from start to the end that all have the potential to lead to mistakes. Medication errors can lead to great costs for healthcare, poor quality of life for the patient or even death. In Sweden it is estimated that 3150 patients die annually caused by medication errors. Purpose: The purpose of this study was to describe medication errors in Landstinget i Östergötland (the County Council of Östergötland) in 2011. Method: Search was done through the error report system, Synergi, with medication error as a priority. From the description in the primary text judge if the report described a medication error. Results: During 2011 2750 reports were submitted to Synergi, and 2320 of these were identified as medication errors. 6,7 % (n=155) of these medication errors had caused harm to the patient, one of them died due to medication error. The most common type of failure was some sort lack of routine (n=1255) and it usually lead to errors of omission; whern a dose that should have been given was not (n=604). Warfarin, an anticoagulantia, was the most frequent drug in the reports (n=140), while a low dose/missed dose of heparin, another anticoagulantia, lead to harm that was classified as serious, to the patients (n=3). MOre than halfr of the reports were fro inpatient care, 52 % (n=1211) and also 80 % (n=125) of medication errors that caused harm to the patients. Conclusion: Lack of routine can be a major cause of medication errors and therefore Swedish healthcare needs to improve routines and even simplify them for easier and faster access for the staff. The cooperation between members of the staff in hospitals, health centers and community home care sholud be better to improve the safety of patients. The healthcare needs more guidance and education to overcome the lack of routines and even more resources for a labor intensive activity where the need for healthcare is increasing

Background: Drug administration is a main duty of a nurse’s clinical role. It involves great risk in patients’ lives and can potentially cause great harm. Despite many safeguards, preventable medication errors still occur. The aim of this descriptive quantitative study is to explore geriatric nurses’ perceptions of medication errors, perceived causes and their reporting behaviours. Methods: A self- report standardized survey was used to collect data from a purpose sample of nurses (n=17) working on geriatric wards at the Montfort hospital located in the province of Ontario. Data entry and analysis were done by using Statistical Package for the Social Sciences (SPSS) version 12 and presented using frequencies, number and percentage. Results: The most frequently identified causes of medication errors were failure to check patient’s name band with the patient’s medication administration record (MAR), nurses' tiredness, illegible physician handwriting, and nurses’ miscalculations of medication doses. In general, nurses were usually sure of constitutes a medication error and when to report it. However, only 30% of errors were perceived by nurses to be reported to the nurse manager. More than half (64.7%) of participants perceived that, some errors are not reported because nurses are afraid of the reaction they will receive from the nurse manager and the majority of them will notify the physician than to complete an incident report. Conclusion: Recognizing a medication error is the first step to reduce report and eliminate them, especially in acute care settings. Finding suggests that nurses need more educational reenforcement as to various issues related to medication errors, particularly defining and reporting these errors. Furthermore, the introduction of hospital policies and the development of structured protocols on drug administration may decrease medication errors. The hospital administration system needs to stress the importance of reporting errors and adopt a non-punitive approach to safeguard patient safety.

Thesis (Master of Nursing)--Cape Peninsula University of Technology, 2019 / One of the most important issues in the provision of healthcare services which threaten the patient's safety, is medication administration errors. These could compromise patient safety and may lead to patient disability or even death, besides the financial cost of these errors. Nurses are responsible for administering medication to numerous patients. They thus are the last defence line against medication administration errors. All student nurses are trained very early in their courses on how to administer medication and all the complications and implications that accompany this important procedure. Although lecturers spend time and effort in teaching nursing students about protocols for safe medication administration, nurses still commit medication administration errors. The aim of the study was to determine awareness and perception of the occurrence and reporting of medication administration errors (MAEs) among nursing students. A descriptive quantitative design was employed. A questionnaire was used to collect data. Responses were collected from 291 nursing students at a higher education institution in the Western Cape, South Africa. Nonprobability proportional quota sampling was used in this study for data collection. Data was analysed with IBM SPSS® software. Data was presented in graphs, percentages, means, and standard deviation, while inferential statistics were conducted. The findings of the study reveal that 85.2% of the respondents were aware of MAE occurrence, but 40.1% were unaware of reporting of these errors. The top and most significant subscale for MAE occurrence was the physician communication subscale, while the top and only significant barrier to reporting these errors was the fear subscale. In conclusion, most of the respondents were aware of MAE occurrence, while more than a third were unaware of the reporting of these errors. The study recommended building non-punitive blame-free reporting systems to emphasise the importance of reporting errors.

Medication errors make up a staggering portion of medical error in the United States. These medication errors are most likely to occur at transitions in care. Children with medical complexity (CMC) often rely on multiple medications to maintain their health, making accurate medication ordering of utmost importance to avoid exacerbating chronic conditions or unnecessary harm. Because of their increased medication usage, CMC have an increased risk of medication ordering error (MOE). To better inform the medication reconciliation process for CMC, we examine the prevalence, category, and risk factors of MOE at hospital admissions for this patient population. A retrospective cohort analysis of 1,237 hospitalized CMC from two tertiary pediatric teaching hospitals with clinical care services for CMC was performed on data from November 1, 2015 to October 31, 2016. Pharmacists and advance nurse practitioners identified MOEs at admissions through medical record review, patient history at interview, and inpatient team discussions. Identified MOEs were classified as one of seventeen different categories, some of which include duplications, omissions, or incorrect frequency, dose, or route. Statistical analysis was performed using Fisher’s exact test, chi-squares, and generalized linear mix models to examine the relationships between MOEs at admission and patient characteristics, such as ethnicity, number of chronic conditions, or number of medications taken at admission. A total of 115 admission MOEs were identified in 73 hospitalized CMC. The two most common MOE types were wrong dose (41.7%) and omitted medication (33.9%). The median number of medications ordered at admission was 10 (IQR 6-14). Medications most commonly associated with an MOE were cholecalciferol (n=9) and baclofen (n=9). As for patient characteristics, the median age at admission was 5 years ([Interquartile Range [IQR] 1-12). Of the total sample, 96.8% had a complex chronic condition and 72.8% were technology dependent. Children who are Black, require medical technology, or take more than 15 medications during hospitalization were found to have higher MOE rates. Multivariable analysis revealed the highest odds of MOE in children taking baclofen (Odds Ratio [OR] 2.6 [95% Confidence Interval {CI} 1.4-4.7]). MOEs at admission are prevalent among hospitalized CMC. Further study on medication safety in CMC is needed to inform medication reconciliation processes and better prevent patient harm. / 2019-07-03T00:00:00Z

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