Patientsäkerhet är ett viktigt ämne inom hälso- och sjukvården. Läkemedelshantering är en del av omvårdnadsarbetet som kan äventyra patientsäkerheten. En fjärdedel av de vårdskador som inträffar beror på fel i läkemedelshanteringen. Studiens syfte var att beskriva händelser och/eller omständigheter i omvårdnadsarbetet som kan riskera patientsäkerheten vid läkemedelshantering. Metoden är litteraturstudie och omfattar 17 artiklar i resultatet som visar att det är flera händelser/omständigheter som bidrar till och ibland samverkar till att medicineringsfel inträffar. Händelser/omständigheter som kunde utgöra en risk för medicineringsfel var: hög arbetsbelastning, övertid, långa arbetspass, kunskapsbrist, låg erfarenhet, kommunikationsbrister, avbrott/distraktion, otydliga ordinationer, bristande kontrollåtgärder av sjuksköterskan samt relation och ansvarsfördelning mellan personalen. Fortsatt forskning bör fokusera på metoder, hjälpmedel och system som kan förhindra att medicineringsfel inträffar och på det sättet spara både pengar och mänskligt lidande. Det är även väsentligt att utvärdera effekterna av den nya patientsäkerhetslagen. / Patient safety is important for health care. Handling of pharmaceutical products is a task within nursing that may jeopardize patient safety. One fourth of the all documented health damages that occur are due to medication errors. The purpose of this study was to describe events and/or circumstances in nursing that can jeopardize patient safety when it comes to handling of pharmaceutical products. The study design is literature study which covers 17 articles in it’s result that shows it’s several events/circumstances that contributes and sometimes work together to make medication errors occur. Events or circumstances that could pose a threat to medication errors was: high workload, overtime, long shifts, lack of knowledge, lack of experience, communication gaps, interruption/distraction, unclear prescription, lack of control measures from the nurse and the relation and responsibilities among staff. Further studies should focus upon methods, tools and systems that can prevent medication errors from occuring and thus save both money and human suffering. It’s also essential to evaluate the effects of the new law concerning patient safety.

Syfte: Syftet med studien var att beskriva vilka faktorer som kan orsaka risk för fel i samband med sjuksköterskans läkemedelshantering samt vad sjuksköterskan kan göra för att förebygga att fel uppstår inom den somatiska slutenvården. Syftet var också att granska artiklarnas kvalité utifrån urval och bortfall. Metod: En beskrivande litteraturstudie som baseras på 13 vetenskapliga artiklar med både kvalitativ och kvantitativ ansats. Litteratursökningen genomfördes i databaserna PubMed, Cinahl och Academic Search Elite. Resultat: Faktorer som orsakade att sjuksköterskan begick fel i läkemedelshanteringen var hög arbetsbelastning, bristande kunskaper inom farmakologi, mindre erfarenhet av sjuksköterskeyrket och avbrott i arbetet. Förebyggande åtgärder för att minimera risken att ett fel uppstod i samband med läkemedelshanteringen var att sjuksköterskan ökade sina kunskaper i farmakologi, bidrog till förbättrad arbetsmiljö och kommunikation med annan vårdpersonal samt var nogrannare vid kontroller. Slutsats: Flera förekommande faktorer som orsakade fel i samband med sjuksköterskans läkemedelshantering som hög arbetsbelastning och bristande kunskaper inom farmakologi borde inte vara svåra att förebygga. Det stora förebyggande arbetet bör ske inom verksamheten för att förbättra arbetsmiljön för sjuksköterskorna och på så vis minska att fel uppstår i samband med läkemedelshanteringen. / Aim: The purpose of this study was to describe the factors that could cause errors associated with the nurse's medication and what the nurse can do to prevent errors from occurring in somatic inpatient care. The aim was also to examine the quality of the articles in relation to sample size and disappearance. Method: A descriptive literature study based on 13 scientific articles with both qualitative and quantitative approach. The literature research was made in the databases PubMed, Cinahl and Academic Search Elite. Results: Factors that caused the nurse to made ​​errors in the handling of drugs was high workload, lack of knowledge in pharmacology, less experience in the nursing profession and working interruptions. Preventive measures to minimize the risk that an error occurred during the drug treatment were that the nurse increased her knowledge of pharmacology, contributed to a better working environment and the communication with other healthcare professionals and was accurate at the controls. Conclusion: Several common factors that caused the errors associated with the nurse's medication as high workload and insufficient of knowledge in pharmacology should not be difficult to prevent. The major preventive measures should be done within the hospital management to improve the working environment for nurses and prevent the error associated with medication management.

Patienter med ögonsjukdomar är en stor patientgrupp som förväntas öka, då många av sjukdomarna är åldersrelaterade och befolkningen i världen blir allt äldre. Ett stort antal av patienterna kommer att förekomma på olika vårdavdelningar där de vårdas av annan orsak. Omvårdnad är sjuksköterskans huvudansvar och hennes profession medför att riktlinjer och lagar ska följas i samband med yrkesutövning. Syftet med pilotstudien var att undersöka sjuksköterskors erfarenheter av att ge omvårdnad till inneliggande patienter med olika ögonsjukdomar i anamnesen. Pilotstudien genomfördes med en kvalitativ metod och datainsamlingen skedde genom intervjuer. Data analyserades med kvalitativ innehållsanalys. Resultatet sammanställdes i tre kategorier: Att erfara bristfälligt ansvarstagande, Att erfara behov av prioriteringar och Att erfara okunskap om ögonsjukvård. Sjuksköterskorna erfor bristfälligt ansvarstagande och de ansåg omvårdnadsarbetet med patienter med olika ögonsjukdomar i anamnesen som svårt. De ansåg sig sakna tillräckligt med kunskap och arbetsbelastningen ledde till att de var tvungna att prioritera på ett sätt som inte gynnade patientgruppen. Sjuksköterskorna uttryckte ett behov av mer utbildning inom detta område. Mer kunskap skulle kunna bidra till att de upplevde en ökad trygghet i sin yrkesroll och leda till en högre patientsäkerhet. Pilotstudien visar att det finns förbättringspotential för att höja patientsäkerheten och som bör följas upp i en fullskalig studie. / Patients with ocular diseases are a large group which is expected to increase since many of the ocular diseases are age-related and world population is aging. These patients are found in various wards where they are inpatients because of other causes than ocular diseases. Nursing care is the nurse´s major responsibility and they are obliged to follow guidelines and laws regularizing their profession. The purpose of this pilot study was to investigate nurses´ experience of providing care for inpatients with any ocular disease, in their anamnesis. The pilot study was conducted using a qualitative content analysis using interviews. The results were compiled into three categories; Experiencing inadequate accountability, Experiencing the need for priorities, and Experiencing the ignorance of ophthalmology. The nurses in the pilot study experienced nursing care to patients with various eye diseases in history difficult. They thought they lacked sufficient knowledge and because of the workload which made them prioritize in a way which did not benefit the patients. The nurses expressed a need of more education in ophthalmic care. More knowledge would support them in experiencing an increased security in their profession and lead to improved patient safety. The pilot study shows that there is potential for improvement to enhance patient safety and should be followed up in a full scale study.

Thesis (M.A.)--Northern Kentucky University, 2008. / Made available through ProQuest. Publication number: AAT 1450571. ProQuest document ID: 1500082951. Includes bibliographical references (p. 76-78)

Thesis (M. Med. Sc.)--University of Hong Kong, 2002. / Includes bibliographical references (leaves 55-61).

Thesis (M.Med.Sc.)--University of Hong Kong, 2002. / Includes bibliographical references (leaves 55-61). Also available in print.

Made available in DSpace on 2014-06-11T19:23:33Z (GMT). No. of bitstreams: 0 Previous issue date: 2008-08-26Bitstream added on 2014-06-13T20:11:00Z : No. of bitstreams: 1 ragazzi_sg_me_arafcf.pdf: 1962785 bytes, checksum: 1c9cdbc9b2f6ca2596e4d8c529bb2b95 (MD5) / Universidade Estadual Paulista (UNESP) / A atenção farmacêutica é uma prática onde o farmacêutico tem a responsabilidade para com o paciente quanto às suas necessidades farmacoterapêuticas, garantindo a eficácia do tratamento e a segurança da farmacoterapia utilizando como instrumento o medicamento. A farmácia hospitalar é um órgão de abrangência assistencial técnico-científico e administrativo onde uma de suas principais funções é estabelecer um sistema racional de distribuição de medicamentos. O objetivo deste estudo foi analisar o sistema de distribuição de medicamentos de uma farmácia hospitalar de um hospital oncológico, bem como identificar os fatores que levam às falhas no processo de distribuição de medicamento. A pesquisa foi realizada na farmácia central de um Hospital Oncológico do Estado de São Paulo em 2007, após aprovação do Comitê de Ética em Pesquisa. A amostra constituiu-se de 3 (12%) farmacêuticos 3 (12%) assistentes de farmácia e 19 (76%) atendentes de farmácia. Todos os profissionais foram consultados quanto a sua disposição para participar do estudo e a seguir, os mesmos assinaram o temo de consentimento livre e esclarecido. Os dados coletados nos mostram que o sistema de distribuição do referido hospital é o sistema por dose individualizada diferenciada, com prescrição eletrônica. Os resultados das observações realizadas durante os 7 dias, indicam o ambiente como principal problema na distribuição de medicamentos (44,77%), pois o local é impróprio, com vários profissionais desenvolvendo atividades diferentes e interrupções freqüentes. Pela observação do ambiente foi possível demonstrar através de fluxogramas todas as ações desenvolvidas pelos profissionais da farmácia desde o momento da chegada da prescrição eletrônica até a entrega dos medicamentos à equipe de enfermagem. As entrevistas... / The pharmaceutical care is a practice where the pharmacist has the responsibility in relation to and with the patient regarding their pharmacotherapeutic needs, guaranteeing the treatment efficiency as well as the pharmacotherapy safety having as its instrument the medicine. The hospital pharmacy is an administrative technical-scientific organ where its main function is to establish a rational system of medicine distribution. The aim of this study was to analyze the medicine distribution system in a hospital pharmacy from an oncologic hospital as well as to identify the factors that lead us to failures related to the medicine distribution process. The survey took place at the central pharmacy from an oncologic hospital in the state of São Paulo after approval of the Committee of the Ethics in Research. The sample includes 3 (12%) pharmacists, 3 (12%) pharmacy assistants and 19 (76%) pharmacy attendants. All the professionals were asked about their willingness to participate in the survey and afterwards they signed on the “Free Will Participation Agreement”. The collected data show us that the distribution system from the above mentioned hospital is the individually differential dose system, with electronic prescription. The results based on the 7 days observation show the environment as the main problem in the medicine distribution (44.77%) once the place is improper and have several professionals performing different activities as well as frequent interruptions. From the environment observation was possible to demonstrate, through the fluxograms, all the actions performed by the pharmacy professionals from the electronic prescription’s arrival until the medicine delivery to the nursing team. The interviews with the professionals show us that the most frequent errors were related to the medicine dispensing (28.05%) and to the medical... (Complete abstract click electronic access below)

Objetivos: Um dos objetivos deste estudo é avaliar as intervenções farmacêuticas realizadas durante o primeiro ano de atuação de farmacêutico junto a equipe multidisciplinar de uma unidade de terapia intensiva (UTI) de hospital de pronto-socorro, público, localizado em Porto Alegre, RS. O estudo se propôs, ainda, a estabelecer uma metodologia para a priorização do cuidado farmacêutico aos pacientes críticos desse hospital. Métodos: Foi realizado um estudo transversal retrospectivo para avaliar as intervenções farmacêuticas no período de maio de 2013 a abril de 2014, a partir de um banco de dados do Serviço de Farmácia. Para estabelecer uma ordem de prioridade para o acompanhamento farmacoterapêutico foi avaliada, prospectivamente, a complexidade da farmacoterapia dos pacientes, através de uma ferramenta chamada Índice de Complexidade da Farmacoterapia adaptado para paciente crítico (ICFT PC), verificando seu grau de associação com o Escore Fisiológico Agudo Simplificado (SAPS3), utilizado como índice prognóstico pela equipe médica. Resultados: No período avaliado retrospectivamente, 426 pacientes internaram na UTI, sendo que 70,6% deles (301) tiveram pelo menos uma intervenção do farmacêutico na sua terapia medicamentosa. Das 602 intervenções realizadas, 53,5% foram relativas à situações qualificadas como erro de medicação. 77,7% do total de intervenções realizadas foram aceitas, sendo o percentual de aceitação superior para as intervenções realizadas devido à erros de medicação (83,2%). Com relação à complexidade da farmacoterapia, 160 pacientes foram avaliados, dos quais 57% eram homens. O ICFT PC dos pacientes variou de 77 a 499, sendo a mediana igual a 164,5. A correlação entre o SAPS3 e o ICFT PC foi de 0,204. Conclusões: O acompanhamento farmacoterapêutico de pacientes críticos permite não apenas a detecção e correção de potenciais erros de medicação, como também a otimização dos resultados terapêuticos e o uso racional de medicamentos. A utilização de uma metodologia para organização deste cuidado farmacêutico e priorização do atendimento à pacientes com maior risco associado à complexidade da farmacoterapia é uma maneira de proporcionar uma assistência mais efetiva, segura e de qualidade aos pacientes do Sistema Único de Saúde. / Objectives: One of the goals of this study is evaluating pharmaceutical interventions done during the first year of pharmaceutical action together with a multidisciplinary team on an intensive care unit (ICU) inside of a public emergency hospital, located in Porto Alegre, Rio Grande do Sul, Brazil. This study is also proposing to establish a methodology to prioritize the pharmaceutical care for critical patients in that hospital. Methods: It was done a retrospective transversal study to evaluate pharmaceutical interventions from May, 2013 to April, 2014, based on a database offered by the Pharmacy Service. To establish a priority order for the pharmacist monitoring, the complexity of patient’s pharmacotherapy was valued, prospectively, through a tool called Pharmacotherapy Complexity Index, which was adapted for critical patients (Medication Regimen Complexity Index for critical patient – MRCI CP). Thus it was possible to verify its level of association with Simplified Acute Physiologic Score (SAPS3) that is used as prognostic index by medical team. Results: On the period evaluated, 426 patients were hospitalized at ICU, 70.6% of them (301) needed at least one pharmaceutical intervention on their drug therapy. Out of the 602 completed interventions, 53.5% were related to situations of medication error. 77.7% of the interventions were accepted; the acceptance percentage was higher for interventions that were done due to medication errors (83.2%). In relation to complexity of pharmacotherapy, 160 patients were evaluated and 57% of them were men. The patients MRCI CP had a range of 77 to 499, being the median 164.5. The correlation between SAPS3 and MRCI CP was 0.204. Conclusions: The pharmacist monitoring of critical patients allows detection and correction of potential medication errors, besides optimization of therapeutic results and rational use of medicines. The use of a methodology to organize this pharmaceutical care and to prioritize the treatment of patients with increased risk associated to complexity of pharmacotherapy is a way of supply an effective, secure and qualified assistance for patients of Unique Health System.

Abstract Background and Objective: An accurate medication history list is an integral part of the patient assessment at hospital admission. The objective of the study was to describe the frequency, type, and predictors of unintentional medication errors and to evaluate the quality of the clinical pharmacy services focusing on the acceptance of the recommendations made by the clinical pharmacist. Setting and methods: A descriptive study was conducted at two internal medicine wards at Baghdad Teaching Hospital in Iraq using Lund Integrated Medicines Management (LIMM)-based medication reconciliation. The study pharmacist conducted medication interviews for patients shortly after hospital admission to obtain the most accurate pre-admission medication history list. This list was compared with the medication list in the patient’s medical chart. Intended addition, withdrawal of a drug, or changes to the dose/ dosage form in the patient’s medical list was considered as medication discrepancies. However, medication discrepancies were considered as medication errors based on no identified clinical reason. Results: A total of 114 patients were included in this study. Over two-thirds of the study patients (73.7%) experienced 215 medication errors identified by a clinical pharmacist conducting medication reconciliation. Most errors were omission (87.9%). Cardiovascular agents followed by NSAID were commonly in error (53%) and (10.2%) respectively. In a logistic regression model, age (odds ratio (OR), 1.055: 95% confidence interval (CI) 1.010 - 1.102), female gender (OR, 3.468: 95% CI 1.232- 9.761) and number of medications at admission (OR, 0.810: 95% CI 0.681-0.963) were predictors for medication history errors at admission. Conclusions: Medication errors at the time of hospital admission are common and undetected.  A structured approach like the LIMM-based medication reconciliation at Iraqi hospital is needed to detect these errors.

Objetivos: Um dos objetivos deste estudo é avaliar as intervenções farmacêuticas realizadas durante o primeiro ano de atuação de farmacêutico junto a equipe multidisciplinar de uma unidade de terapia intensiva (UTI) de hospital de pronto-socorro, público, localizado em Porto Alegre, RS. O estudo se propôs, ainda, a estabelecer uma metodologia para a priorização do cuidado farmacêutico aos pacientes críticos desse hospital. Métodos: Foi realizado um estudo transversal retrospectivo para avaliar as intervenções farmacêuticas no período de maio de 2013 a abril de 2014, a partir de um banco de dados do Serviço de Farmácia. Para estabelecer uma ordem de prioridade para o acompanhamento farmacoterapêutico foi avaliada, prospectivamente, a complexidade da farmacoterapia dos pacientes, através de uma ferramenta chamada Índice de Complexidade da Farmacoterapia adaptado para paciente crítico (ICFT PC), verificando seu grau de associação com o Escore Fisiológico Agudo Simplificado (SAPS3), utilizado como índice prognóstico pela equipe médica. Resultados: No período avaliado retrospectivamente, 426 pacientes internaram na UTI, sendo que 70,6% deles (301) tiveram pelo menos uma intervenção do farmacêutico na sua terapia medicamentosa. Das 602 intervenções realizadas, 53,5% foram relativas à situações qualificadas como erro de medicação. 77,7% do total de intervenções realizadas foram aceitas, sendo o percentual de aceitação superior para as intervenções realizadas devido à erros de medicação (83,2%). Com relação à complexidade da farmacoterapia, 160 pacientes foram avaliados, dos quais 57% eram homens. O ICFT PC dos pacientes variou de 77 a 499, sendo a mediana igual a 164,5. A correlação entre o SAPS3 e o ICFT PC foi de 0,204. Conclusões: O acompanhamento farmacoterapêutico de pacientes críticos permite não apenas a detecção e correção de potenciais erros de medicação, como também a otimização dos resultados terapêuticos e o uso racional de medicamentos. A utilização de uma metodologia para organização deste cuidado farmacêutico e priorização do atendimento à pacientes com maior risco associado à complexidade da farmacoterapia é uma maneira de proporcionar uma assistência mais efetiva, segura e de qualidade aos pacientes do Sistema Único de Saúde. / Objectives: One of the goals of this study is evaluating pharmaceutical interventions done during the first year of pharmaceutical action together with a multidisciplinary team on an intensive care unit (ICU) inside of a public emergency hospital, located in Porto Alegre, Rio Grande do Sul, Brazil. This study is also proposing to establish a methodology to prioritize the pharmaceutical care for critical patients in that hospital. Methods: It was done a retrospective transversal study to evaluate pharmaceutical interventions from May, 2013 to April, 2014, based on a database offered by the Pharmacy Service. To establish a priority order for the pharmacist monitoring, the complexity of patient’s pharmacotherapy was valued, prospectively, through a tool called Pharmacotherapy Complexity Index, which was adapted for critical patients (Medication Regimen Complexity Index for critical patient – MRCI CP). Thus it was possible to verify its level of association with Simplified Acute Physiologic Score (SAPS3) that is used as prognostic index by medical team. Results: On the period evaluated, 426 patients were hospitalized at ICU, 70.6% of them (301) needed at least one pharmaceutical intervention on their drug therapy. Out of the 602 completed interventions, 53.5% were related to situations of medication error. 77.7% of the interventions were accepted; the acceptance percentage was higher for interventions that were done due to medication errors (83.2%). In relation to complexity of pharmacotherapy, 160 patients were evaluated and 57% of them were men. The patients MRCI CP had a range of 77 to 499, being the median 164.5. The correlation between SAPS3 and MRCI CP was 0.204. Conclusions: The pharmacist monitoring of critical patients allows detection and correction of potential medication errors, besides optimization of therapeutic results and rational use of medicines. The use of a methodology to organize this pharmaceutical care and to prioritize the treatment of patients with increased risk associated to complexity of pharmacotherapy is a way of supply an effective, secure and qualified assistance for patients of Unique Health System.