Rótulos de medicamentos na perspectiva dos profissionais de saúde brasileiros: dificuldades, nível de satisfação e melhorias propostas

Autores

  • Cassia G. MORAES
  • Tatiane S. DAL PIZZOL
  • Maicon FALAVIGNA
  • Lisana R. SIRTORI
  • Fernanda CRUZ
  • Guilherme WEBSTER
  • Emilia S. PONS

DOI:

https://doi.org/10.30968/rbfhss.2022.134.0875

Resumo

Objetivo: Avaliar as percepções de profissionais da saúde sobre situações de erros de medicação associado a rotulagem. Métodos: Estudo transversal com 1.056 técnicos de enfermagem, enfermeiros e farmacêuticos entrevistados em 10 capitais brasileiras. Avaliamos a percepção dos participantes sobre a dificuldade em diferenciar ou ver as informações nos rótulos, a probabilidade de ocorrer um erro de medicação e a frequência de erros de medicação, incluindo: 1) frascos ou rótulos semelhantes; 2) duas embalagens do mesmo medicamento, mas com doses diferentes; 3) rótulos de ampolas; 4) rótulos das embalagens blister; e 5) etiquetas impressas nas embalagens secundárias. Resultados: A maioria dos participantes relatou ser difícil ou muito difícil diferenciar entre frascos idênticos (82,4%) e entre diferentes doses do mesmo medicamento (82,5%). A identificação de informações importantes sobre ampolas, blisters e embalagens secundárias foi considerada difícil ou muito difícil por 89,9%, 64,4% e 48,9% dos participantes, respectivamente. Aproximadamente metade dos participantes relatou que um erro era mais provável de ocorrer em situações envolvendo dificuldade em ver as informações em uma ampola, rótulos semelhantes e embalagens do mesmo medicamento, mas com doses diferentes. Conclusão: A dificuldade em pelo menos uma das situações que envolvem a identificação ou diferenciação dos rótulos dos medicamentos é comum entre os profissionais de saúde, levando a uma maior probabilidade de erros de medicação.

Downloads

Não há dados estatísticos.

Referências

World Health Organization (WHO). WHO Global Patient Safety Challenge: Medication Without Harm. Available in: https://www.who.int/patientsafety/medication-safety/medication-without-harm-brochure/en/. Accessed on: 7st Nov 2021.

Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington (DC): National Academies Press 2000. Available in: https://www.ncbi.nlm.nih.gov/books/NBK225182/. Accessed on: 7st Nov 2021.

Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academies Press 200. Available in: https://www.ncbi.nlm.nih.gov/books/NBK222278/. Accessed on: 7st Nov 2021.

Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:517-9. DOI: 10.1136/bmj.322.7285.517

Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004;170:1678-86. DOI:10.1503/cmaj.1040498

Soop M, Fryksmark U, Koster M, et al. The incidence of adverse events in Swedish hospitals: a retrospective medical record review study. Int J Qual Health Care 2009;21:285-91. DOI:10.1093/intqhc/mzp025

7. de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care . 2008;17(3):216-23. DOI: 10.1136/qshc.2007.023622.

Mendes W, Martins M, Rozenfeld S, Travassos C. The assessment of adverse events in hospitals in Brazil. International Journal for Quality in Health. Care 2009; 21(4):279-284. DOI: 10.1093/intqhc/mzp022

Sousa P, Uva AS, Serranheira F, Nunes C, Leite ES. Estimating the incidence of adverse events in Portuguese hospitals: a contribution to improving quality and patient safety. BMC Health Serv Res. 2014 18;14:311. DOI: 10.1186/1472-6963-14-311.

Bates DW. A 40-year-old woman who noticed a medication error. JAMA 2001;285:3134-40. DOI:10.1001/jama.285.24.3134

Brasil. Ministério da Saúde. Resolução da Diretoria Colegiada - RDC No 71, DE 22 DE DEZEMBRO DE 2009. Estabelece regras para a rotulagem de medicamentos. Available in: http://portal.anvisa.gov.br/documents/33880/2568070/res0071_22_12_2009.pdf/84755241-6284-48f9-a446-ec9d34841622. Accessed on: 7st Nov 2021.

Pons E, Moraes CG, Falavigna M, et al. Users’ preferences, perceptions and understanding of medication labels. Plos One 2019;14: e0212173. DOI: 10.1371/journal.pone.0212173l.

Australian Government. Department of health. Medicine labels: Guidance on TGO 91 and TGO 92. Available in: https://www.tga.gov.au/medicine-labels-guidance-tgo-91-andtgo-92. Accessed on: 7st Nov 2021.

Peterson GM, Wu MS, Beggin JK. Pharmacists’ attitudes towards dispensing errors, their causes and prevention. J Clin Pharm Ther. 1999;24(1):57–71. DOI: 10.1046/j.1365-2710.1999.00199.x.

E. Hellier, J. Edworthy, N. Derbyshire & A. Costello. Considering the impact of medicine label design characteristics on patient safety, Ergonomics.2006;49(5-6):617-30. DOI: 10.1080/00140130600568980.

European commission. Enterprise and industry directorate-general. Guideline on the readability of the labelling and package leaflet of medicinal products for human use. Available in: https://ec.europa.eu/health//sites/health/files/files/eudralex/vol-2/c/2009_01_12_readability_guideline_final_en.pdf. Accessed on: 7st Nov 2021.

National Patient Safety Agency THHRC. Design for patient safety: A guide to the graphic design of medication packaging. Second Edtion. London, UK: National Health Service; 2007. Available in: http://www.hhc.rca.ac.uk/cms/files/npsa-design-for-patient-safety-.pdf. Accessed on: 7st Nov 2021.

National Patient Safety Agency THHRC. Design for patient safety: A guide to labelling and packaging of injectable medicines. Edition 1. London, UK: National Health Service; 2008. Available from: http://ezdrugid.org/EZDrugID/Strategies_files/NHSInjectableMedLabels.pdf. Accessed on:7st Nov 2021.

U.S. Department of Health and Human Services. Food and Drug Administration. Center for Drug Evaluation and Research (CDER). Safety considerations for product design to minimize medication errors. Guidance for Industry. Available in: https://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm331810.pdf. Accessed on: 7st Nov 2021.

Government of Canada. Good Label and Package Practices Guide for Prescription Drugs. Available in: https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/pubs/medeff/guide/2016-label-package-practices-pratiques-etiquetage-emballage-rx/glppg-gbpee-rx-eng.pdf. Accessed on: 7st Nov 2021.

Hellebek A, Schytte-Hansen S, Fischer H, et al. Patient safety in drug label design: analysis of reported adverse events before and after introducing a new label design. Eur J Hosp Pharm Sci Pract 2013;20:212-17.

Cohen MR. ISMP Medication error report analysis – Cross contamination with insulin pens; Look-alike vials; Kids and medication patches; New look-alike name pair; Preventing dosing errors with methotrexate injection. Hosp Pharm 2008;43:445–47. DOI:10.1310/hpj4306-445

Institute for Safe Medication Practices Canada (ISMP Canada). Labelling and packaging: an aggregate analysis of medication incident report. Available in: https://www.ismp-canada.org/download/LabellingPackaging/ISMPC2013_LabellingPackaging_FullReport.pdf. Accessed on: 7st Nov 2021.

Taneja N, Wiegmann DA. The role of perception in Medication Errors : Implications for Non-Technological Interventions. Med J Armed Forces India 2004;60(2):172-6. DOI:10.1016/S0377-1237(04)80112-6

Phillips J, Beam S, Brinker A, et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm 2001;58:1835-41. DOI: 10.1093/ajhp/58.19.1835

Government of Canada IC. Good Label and Package Practices Guide for Non-prescription Drugs and Natural Health Products. Government of Canada, ISMP Canada; 2018. Available in: https://www.canada.ca/content/dam/hc-sc/documents/services/drugs-health-products/reports-publications/medeffect-canada/good-label-package-practices-guide-nonprescription-drugs-natural-health-products-guidance/ goodlabel-st package-practices-guide-non-prescription-drugs-natural-health-products-eng.pdf. Accessed on: 7st Nov 2021.

Institute of Medicine. Preventing medication errors. Available in: https://www.nap.edu/catalog/11623/preventing-medication-errors. Accessed on: 7st Nov 2021.

Orser BA, Chen RJ, Yee DA. Medication errors in anesthetic practice: a survey of 687 practitioners. Can J Anaesth 2001;48:139-46. DOI:10.1007/BF03019726

Llewellyn RL, Gordon PC, Wheatcroft D, et al. Drug administration errors: a prospective survey from three South African teaching hospitals. Anaesth Intensive Care 2009;37:93-8. DOI: 10.1177/0310057X0903700105

Abeysekera A, Bergman IJ, Kluger MT, et al. Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database. Anaesthesia 2005;60:220-7. DOI:10.1111/j.1365-2044.2005.04123.x

Larmene-Beld KHM, Alting EK, Taxis K. A systematic literature review on strategies to avoid look-alike errors of labels. Eur J Clin Pharmacol 2018;74(8):985-99. DOI:10.1007/s00228-018-2471-z

Hellier E, Tucker M, Kenny N, Rowntree A, Edworthy J. Merits of using color and shape differentiation to improve the speed and accuracy of drug strength identification on over-thecounter medicines by laypeople. J Patient Saf . 2010;6(3):158-64. DOI: 10.1097/pts.0b013e3181eee157.

Endestad T, Wortinger LA, Madsen S, Hortemo S. Package Design Affects Accuracy Recognition for Medications. Human factors. 2016;58(8):1206-16. DOI: 10.1177/0018720816664824.

Gupta B, Gupta SK, Suri S, et al. Efficacy of contrasting background on a drug label: A prospective, randomized study. J Anaesthesiol Clin Pharmacol 2015;31:230-3. DOI:10.4103/0970-9185.155154

ISMP Updates its List of Drug Name Pairs with TALL Man Letters. Available in: https://www.medscape.com/viewarticle/736754. Accessed on: 7st Nov 2021.

Filik R, Purdy K, Gale A, Gerrett D. Drug name confusion: evaluating the effectiveness of capital (“Tall Man”) letters using eye movement data. Soc Sci Med. 2004; 59:2597–601. DOI: 10.1016/j.socscimed.2004.04.008.

Publicado

2022-12-27

Como Citar

1.
MORAES CG, DAL PIZZOL TS, FALAVIGNA M, SIRTORI LR, CRUZ F, WEBSTER G, PONS ES. Rótulos de medicamentos na perspectiva dos profissionais de saúde brasileiros: dificuldades, nível de satisfação e melhorias propostas. Rev Bras Farm Hosp Serv Saude [Internet]. 27º de dezembro de 2022 [citado 16º de julho de 2024];13(4):875. Disponível em: https://rbfhss.org.br/sbrafh/article/view/875

Edição

Seção

ARTIGOS ORIGINAIS

Artigos mais lidos pelo mesmo(s) autor(es)