Medication errors in an intensive care unit

Medication errors in an intensive care unit

Author Bohomol, Elena Autor UNIFESP Google Scholar
Ramos, Lais Helena Autor UNIFESP Google Scholar
D'Innocenzo, Maria Autor UNIFESP Google Scholar
Institution Sao Camilo Univ Ctr
Universidade Federal de São Paulo (UNIFESP)
Abstract Medication errors in an intensive care unit.This paper is a report of a study to investigating the incidence types and causes of medication errors (MEs) and the consequences for patients.Medication errors are a common problem in hospitals around the world, including those in Brazil.An exploratory, quantitative survey design was used and 44 adult inpatients were studied over a 30-day period in 2006. Three different methods were employed: anonymous self-reports, staff interviews and review of patient prescriptions.A total of 305 MEs was observed. the mean (sd) number was 6.9 (6.8) per patient. the numbers of MEs per day differed statistically significantly between the two groups with length of stay in the intensive care unit of < 1 week and more than 1 week, respectively, with mean (sd) of 0.4 (0.38) vs. 0.73 (0.39) the most frequent types were: omission (71.1%), wrong time of administration (11.5%), and prescribing errors (4.6%). the main causes were: medication not available in the hospital (41%); pharmacy stocking and delivery problems (16.3%); transcription errors (11%). No death was directly related to any ME.There is a need to develop a culture of safety and quality in patient care. An understanding of the profile of ME types and frequencies in an institution is fundamental to raise awareness and implement measures to avoid them. Structural and procedural changes in hospital organization, with a focus on the efficacy, efficiency, and effectiveness of the medication system are needed to reduce MEs.
Keywords adults
anonymous reports
Brazil
healthcare professionals
intensive care
interviews
medication errors
record reviews
Language English
Date 2009-06-01
Published in Journal of Advanced Nursing. Malden: Wiley-Blackwell Publishing, Inc, v. 65, n. 6, p. 1259-1267, 2009.
ISSN 0309-2402 (Sherpa/Romeo, impact factor)
Publisher Wiley-Blackwell
Extent 1259-1267
Origin http://dx.doi.org/10.1111/j.1365-2648.2009.04979.x
Access rights Closed access
Type Article
Web of Science ID WOS:000265426900013
URI http://repositorio.unifesp.br/handle/11600/31587

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