análise de causa raiz: avaliação de erros de medicação em um hospital universitário análisis de causa raíz: evaluación de errores de medicación en un hospital universitario root cause analysis: evaluation of medication errors at a university hospital
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Abstract
Los objetivos de este estudio consistieron en identificar y analizar los tipos de errores de medicación observados en las dosis de medicamentos que fueron preparadas y administradas de modo diferente respecto del cual fueron prescriptas. El estudio fue de carácter descriptivo, se utilizó el método de análisis de causa raíz, efectuado en forma secundaria sobre los resultados de un estudio ya existente. En el estudio, 74 errores de medicación fueron identificados durante la preparación y la administración de medicamentos por parte del equipo de Enfermería. Errores de dosis (24,3%), errores de horario (22,9%) y medicamentos no autorizados (13,5%) fueron los más frecuentes. Así, el análisis de causa raíz fue realizado, identificándose múltiples factores que contribuyeron para la ocurrencia de los errores. Fueron presentadas estrategias y recomendaciones para evitarlos.
The objectives of this study were to identify and analyze the types of medication errors observed in doses prepared and administered differently from those prescribed. It is a descriptive study using the root cause analysis method, in which a secondary analysis of data from a previously existing investigation was performed. In the study, 74 medication errors were identified during medication preparation and administration by the nursing staff. Dose errors (24.3%), schedule errors (22.9%) and unauthorized medication administration errors (13.5%) were the most frequent. Hence, medication errors were identified, and root cause analysis was performed, leading to the identification of multiple factors that contributed to error occurrence. Strategies and recommendations were presented for the prevention of errors.
| Reference Key |
teixeira2010revistaanlise
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|---|---|
| Authors | ;Thalyta Cardoso Alux Teixeira;Silvia Helena De Bortoli Cassiani |
| Journal | FEMS microbiology letters |
| Year | 2010 |
| DOI |
10.1590/S0080-62342010000100020
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| URL | |
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