Prescription’s errors of high alert medicines in a Tertiary hospital of distrito federal

Abstract

Introduction: High-alert medications are a priority for determination of errors and identification of preventive actions to improve patient safety. The prescription is the first step in the process of using medicines and any failure in this phase may cause problems in the subsequent steps, increasing medication error statistics. Goals: To analyze the profile of high-alert medications (HAM) prescriptions in the General Practice Unit of the Federal District Base Hospital (HBDF). Methods: It is a cross-sectional, descriptive and retrospective observational analysis based on high-alert medications prescriptions analysis of inpatients, during 8 days between July, 15 and September, 15 of 2015. Clinic and demographic data collected regarding HAM and prescription errors, such as the use of abbreviation, the omission of information and absence of the metric system were analyzed using descriptive statistics and the chi-square association test, with the aid of Statistical Package for Social Sciences Program (SPSS). Results: there were 292 prescriptions analyzed. Of them, 187 contained high-alert medication, totaling 111 patients. During the days of investigation, the high-alert medication was prescribed 411 times. A total of 1,942 errors were identified and the most frequent one was missing information (85%). Regular human insulin, 50% glucose solution, enoxaparin, and tramadol are among the high-alert medication most involved with writing error. Conclusions: The results suggest a necessity of standardization of the prescription process and improvement of the electronic prescribing system, incorporating safety practices to prevent the identified errors.