Medication errors: a risk of health care
Keywords:
Erros de medicação. Segurança do paciente. Cuidados de saúde.Abstract
Objectives: To contribute to the understanding of medication errors (ME) with their identification and analysis and further development of preventive recommendations.
Methodology: A retrospective observational study of notifications received by The National Toxicology Information Advisory Center from November 2009 to April 2011. The variables studied were age, sex, origin of the consultation, therapeutic group, error type, severity, location of incident, condition, previous medical interventions and resolution. The data analysis was performed using Microsoft Office Excel 2007 software. The ATC classification was applied to the drugs involved in the error and the ICD 10 for classifying pathologies. The type and the severity of the ME were established taking into account the NCC MERP taxonomy and WHO criteria.
Results: 79 notifications (39 male and 40 female) were analyzed. The most common type of ME was wrong medication (34), followed by wrong dose (30). 43% of the errors produced harm to the patient (E and F categories). 75% of notifications came from health care centers. Older people (60 to 74 years) were more affected by ME. The drugs commonly involved in errors were those used for central nervous system pathologies, followed by hormones and analgesics. 100% of the queries had an immediate response: treatment or recommendations.
Conclusions: Based on the interdisciplinary work we were able to identify and minimize the consequences of ME, making recommendations involving health authorities, pharmaceutical industry, hospital managers, health personnel, patients, families and caregivers.
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