Analysis of the compliance of Prescription of High Alert Medication for Onco-hematologic Patients in a Teaching Hospital

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DOI:

https://doi.org/10.30968/rbfhss.2022.134.0836

Abstract

requirements of the Protocol for Prescription, Use and Administration of Medicines from Ministry of Health. Method: Cross-sectional study, with prescriptions for onco-hematologic patients in a university teaching unit in the Midwest region of Brazil. The variables were defined as recommended by the Ministry of Health protocol. Data were analyzed using STATA 14.1 software. Results: 57 prescriptions were analyzed and a total of 659 medications were prescribed, of which 20.2% (n=133) were HAM. The most prescribed HAM were tramadol 21.0% (n=28), morphine 19.5% (n=26) and glucose 13.6% (n=18). Regarding non-compliance, 88.0% (n=117) of HAM showed at least one disagreement regarding protocol. Medications prescribed for the central nervous system were the most associated with non-compliance. In all, 266 non-compliance were identified, among which the majority, 18.4% (n=49) were related to the use of vague expressions, 16.2% (n=43) to the absence of infusion time and 11.8% (n=31) the presence of abbreviations. Conclusion: Most HAM prescriptions showed non-compliance regarding Ministry of Health protocol. The main were related to the inappropriate use of vague expressions, omission of infusion time and use of abbreviations. These findings highlight the need to improve the quality of prescriptions and the development of strategies to intercept errors, such as checklists and informational materials.

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References

Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000.

James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013 Sep;9(3):122-8. DOI: 10.1097/PTS.0b013e3182948a69.

NCC MERP. The National Coordination Council for Medication Error and Prevention Report. About Medication Errors.What is a Medication Error?. Available in: http://www.nccmerp.org/aboutmedication-errors. Accessed on: 08 th Nov 2021.

Elliott RA, Camacho E, Jankovic D, et al. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf. 2021;30(2):96-105. DOI: 10.1136/bmjqs-2019-010206.

Kavanagh C. Medication governance: preventing errors and promoting patient safety. Br J Nurs. 2017;26(3):159-165. DOI:10.12968/bjon.2017.26.3.159.

Cousins DH, Gerrett D, Warner B. A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005-2010). Br J Clin Pharmacol. 2012;74(4):597-604. DOI: 10.1111/j.1365-2125.2011.04166.x.

Dalmolin GR, Rota ET, Goldim JR. Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital. Braz J Pharm Sci. 2013;49 (4). DOI: 10.1590/S1984-82502013000400019.

Lewis PJ, Dornan T, Taylor D, et al. Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review. Drug Saf. 2009;32(5):379-89. Doi:10.2165/00002018-200932050-00002.

Souza AF, Queiroz JC, Vieira NA, et al. Os erros de medicação e os fatores de risco associados a sua prescrição. Enferm. Foco. 2013;10 (4):12-16. DOI: 10.21675/2357-707X.2019.

Jacobsen TF, Mussi MM, Silbeira MPT. Analysis of prescription errors in a hospital of southern Brazil. Rev. Bras. Farm. Hosp. Serv. Saúde. 2015; 6(3): 23-26.

Institute for Safe Medication Practices (ISMP EUA). High-Alert Medication Survey Results Lead to Several Changes for 2018 2018. Available in: https://www.ismp.org/resources/high--alert-medication-survey-results-lead-several-changes-2018. Accessed on: 20 th Dec 2021.

Gaunt MJ, Cohen M R. Error-prone abbreviations and dose expressions. In: American Pharmacists Association. Medication errors, 2nd ed. Washington (DC): American Pharmacists Association, 2007: 153-71.

Ministério da Saúde. Programa Nacional de Segurança do Paciente – Anexo 03: Protocolo de segurança na prescrição, uso e administração de medicamentos. Agência Nacional de Vigilância Sanitária, Brasília, DF, 2013a. Available in: https://repositorio.observatoriodocuidado.org/bitstream/handle/handle/1650/protoc_identificacaoPaciente.pdf?sequence=1&isAllowed=y. Accessed on: 02 nd Sep 2020.

Gomes A, Galato, D, Silva EV. Prescription’s errors of high alert medicines in a tertiary hospital of Distrito Federal. Rev. Bras. Farm. Hosp. Serv. Saúde. 2017; 08(3):42-47. DOI: 10.30968/rbfhss.2017.083.008.

Delpeuch A, Leveque D, Gourieux B, et al. Impact of Clinical pharmacy services in a hematology/oncology inpatient setting. Anticancer Res. 2015;35(1):457-60.

Visacri MB, Tavares MG, Barbosa CR, et al. Clinical Pharmacy in onco-hematology and bone marrow transplant: A valuable contribution to improving patient safety. J Oncol Pharm Pract. 2021;27(5):1172-1180. doi: 10.1177/1078155220943964.

Otero MJ, Toscano Guzmán MD, Galván-Banqueri M, et al. Utility of a trigger tool (TRIGGER-CHRON) to detect adverse events associated with high-alert medications in patients with multimorbidity. Eur J Hosp Pharm. 2021;28(Suppl 2):e41-e46. doi: 10.1136/ejhpharm-2019-002126.

World Health Organization (WHO). Global patient safety challenge: medication without harm. Geneva: World Health Organization; 2017. Available in: http:// www.who.int/patientsafety/medication-safety/en/. Accessed on: 01 st Nov 2021.

Miot HA. Tamanho da amostra em estudos clínicos e experimentais. Jornal Vascular Brasileiro. Sociedade Brasileira de Angiologia e de Cirurgia (SBACV). 2011; 10 (4): 275-278.

Otero MJ, Dominguez-Gil A. Acontecimentos adversos por medicamentos: Uma patologia emergente. Farm hosp. 2000 ; 24(4):258-266.

Harris PA, Taylor R, Minor BL, et al. REDCap Consortium. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019; 95:103208. DOI: 10.1016/j.jbi.2019.103820.

Instituto para práticas seguras no uso de medicamentos (ISMP Brasil). Nomes de medicamentos com grafia ou som semelhantes: como evitar os erros?. ISMP. 2014; 3(6).

Eishy Oskuyi A, Sharifi H, Asghari R. Medication errors in hematology-oncology ward by consultation: The role of the clinical pharmacologist. Caspian J Intern Med. 2021;12(1):53-58. DOI: 10.22088/cjim.12.1.53.

Barbosa IM, Sales DS, OliveiraLMS, et al. Pain in onco-hematologic patients and its association with analgesia. Revista Dor. 2016; 17(3):178-182. Doi 10.5935/1806-0013.20160066.

Maia JLB, Batista RFL, Rosa MB, et al. Identification of risks and practices in the use of high alert medications in a university hospital. Rev Min Enferm. 2020; 24:e-1311. DOI: 10.5935/1415-2762.20200048.

Fallon M, Giusti R, Aielli F, et al. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2018; 29(4):166-191. DOI: 10.1093/annonc/mdy152.

Alanazi MA, Tully MP, Lewis PJ. A systematic review of the prevalence and incidence of prescribing errors with high-risk medicines in hospitals. J Clin Pharm Ther. 2016;41(3):239-45. DOI: 10.1111/jcpt.12389.

Isaacs AN, Ch’ng K, Delhiwale N, et al. Hospital medication errors: a cross-sectional study. Int J Qual Health Care. 2021;33(1):mzaa136. DOI: 10.1093/intqhc/mzaa136.

Roy S, Eiden C, Rasanjison I, et al. Network of French Pharmacovigilance Centers; Network of French Addictovigilance Network. Medication errors involving opioid maintenance therapy. Therapie. 2020;75(3):295-297. DOI: 10.1016/j.therap.2019.07.007.

Herzig SJ, Stefan MS, Pekow PS, et al. Risk Factors for Severe Opioid-Related Adverse Events in a National Cohort of Medical Hospitalizations. J Gen Intern Med. 2020;35(2):538-545. DOI: 10.1007/s11606-019-05490-w.

Tariq RA, Sharma S. Inappropriate Medical Abbreviations. In: StatPearls. Treasure Island (FL): StatPearls Publishing, 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519006/. Accessed on: 20 th Dec 2021

Haseeb A, Winit-Watjana W, Bakhsh AR, et al. Effectiveness of a pharmacist-led educational intervention to reduce the use of high-risk abbreviations in an acute care setting in Saudi Arabia: a quasi-experimental study. BMJ Open. 2016;6(6):e011401. DOI: 10.1136/bmjopen-2016-011401.

Takahashi MM, Nascimnto JC, Junior VLC, et al. Avaliação da prescrição: potenciais problemas que podem induzir ao erro na dispensação de medicamentos. Unisanta Health Science. 2020; 4(1): 30-37.

Zhou L, Maviglia SM, Mahoney LM, et al. Supratherapeutic dosing of acetaminophen among hospitalized patients. Arch Intern Med. 2012;172(22):1721-8. DOI: 10.1001/2013.jamainternmed.438.

Kim B, Nolan S, Beaulieu T. et al. Inappropriate opioid prescribing practices: A narrative review. Am J Health Syst Pharm. 2019;76(16):1231-1237. DOI: 10.1093/ajhp/zxz092.

Reinhardt H, Otte P, Eggleton AG, et al. Engelhardt M. Avoiding chemotherapy prescribing errors: Analysis and innovative strategies. Cancer. 2019;125(9):1547-1557. DOI: 10.1002/cncr.31950.

ISMP. Institute of Safe Medication Practices, ISMP. 2019. Available in: https://www.ismp.org/Tools/confuseddrugnames.pdf. Accessed on:10th Jan 2022.

Ruutiainen HK, Kallio MM, Kuitunen SK. Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. Eur J Hosp Pharm. 2021; 28(Suppl 2):e151-e156. DOI: 10.1136/ejhpharm-2020-002531.

Larmené-Beld KHM, Alting EK, Taxis K. A systematic literature review on strategies to avoid look-alike errors of labels. Eur J Clin Pharmacol. 2018 Aug;74(8):985-993. DOI: 10.1007/s00228-018-2471-z.

Emmerton L, Curtain C, Swaminathan G, et al. Development and exploratory analysis of software to detect look-alike, sound-alike medicine names. Int J Med Inform. 2020;137:104119. DOI: 10.1016/j.ijmedinf.2020.104119.

Bryan R. Aronson JK, Williams AJ, et al. A systematic literature review of LASA error interventions. Br J Clin Pharmacol. 2020;87 (2):336-351. DOI: 10.1111/bcp.14644.

Micromedex® Neo fax. Version 3.1.1(290). Copyright 2013. 2021 IBM. Accessed on: 20 th Dec 2020.

Instituto para práticas seguras no uso de medicamentos (ISMP Brasil). Medicamentos Potencialmente Perigosos De Uso Hospitalar- lista atualizada 2019. ISMP. 2019; 8(1).

World Health Organization (WHO). Collaborating Centre for Drug Statistics Methodology. ATC/DDD Index 2021. Available in: https://www.whocc.no/atc_ddd_index/. Accessed on: 3 rd Jun 2021.

Published

2022-12-06

How to Cite

1.
MOREIRA PR, FARIAS LT, FERREIRA TM, SILVA LT, MAGALHÃES JC, SOUSA PC, MODESTO AC. Analysis of the compliance of Prescription of High Alert Medication for Onco-hematologic Patients in a Teaching Hospital. Rev Bras Farm Hosp Serv Saude [Internet]. 2022Dec.6 [cited 2024Jul.16];13(4):836. Available from: https://rbfhss.org.br/sbrafh/article/view/836

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ORIGINAL ARTICLES