Bohomol Elena, Ramos Lais Helena, D'Innocenzo Maria
Nursing and Health Services Evaluation Studies and Research Group, São Paulo Federal University, São Paulo, Brazil.
J Adv Nurs. 2009 Jun;65(6):1259-67. doi: 10.1111/j.1365-2648.2009.04979.x. Epub 2009 Apr 3.
This paper is a report of a study to investigating the incidence types and causes of medication errors (MEs) and the consequences for patients. Background. 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.
本文是一项关于调查用药差错的发生率、类型、原因及对患者影响的研究报告。背景：用药差错是全球医院包括巴西医院在内的一个常见问题。
采用探索性定量调查设计，于2006年对44名成年住院患者进行了为期30天的研究。采用了三种不同方法：匿名自我报告、员工访谈和患者处方审查。
共观察到305例用药差错。每位患者的平均（标准差）差错数为6.9（6.8）。入住重症监护病房时间分别小于1周和超过1周的两组患者每天的用药差错数在统计学上有显著差异，平均（标准差）分别为0.4（0.38）和0.73（0.39）。最常见的类型为：漏用（71.1%）、给药时间错误（11.5%）和处方错误（4.6%）。主要原因有：医院无药（41%）；药房库存和配送问题（16.3%）；转录错误（11%）。没有死亡与任何用药差错直接相关。
需要在患者护理中培养安全和质量文化。了解机构内用药差错的类型和频率概况对于提高认识和采取措施避免差错至关重要。需要对医院组织进行结构和程序变革，重点关注用药系统的有效性、效率和效能，以减少用药差错。
