Dispensing errors in a public cardiopulmonary hospital
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Descritores: Erros de medicação, Indicadores de qualidade, Segurança do paciente.Abstract
Objective: To identify and evaluate the frequency of types of medication dispensing errors and their potential causes, in a public cardiopulmonary hospital.
Methods: This was a prospective observational study carried out at a hospital pharmacy care to inpatients of a public cardiopulmonary hospital in the period from September to November 2014. After considering the separated medicines, dispensing errors were collected in a proper form, tabulated in spreadsheets (Excel) and presented by management tools: Pareto analysis to evaluate the frequency of the types of errors; Ishikawa diagram for evaluation the potential causes of errors; and indicator "error rate in dispensing drugs" to measure process performance.
Results: Were found 95 errors in dispensing drugs of 1971 separated prescriptions that were categorized as "unidentified or unreadable" (29.5%), "overdose" (18.9%), "omission dose" (17.9%), "dispensed differs from the prescribed" (14.7%), "expired" (12.6%) and "lower concentration" (6.3%). The error rate in dispensing medicines obtained was 0.74%. The potential causes of these errors are associated with improper storage, interruptions in the separation procedure, lack of standardization of procedures; memory lapses and lack of continuing education.
Conclusion: It was observed in the field and in the literature that the errors in dispensing drugs is a permanent risk in hospitals. Thus this process needs to be continuously evaluated. The management tools used assisted in identifying, analyzing and measuring the results being useful in monitoring the dispensing process for improvement.
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