Teixeira Thalyta Cardoso Alux, de Cassiani Silvia Helena Bortoli
Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil.
Rev Esc Enferm USP. 2010 Mar;44(1):139-46. doi: 10.1590/s0080-62342010000100020.
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.
本研究的目的是识别和分析在准备和给药剂量方面与处方不同时所观察到的用药错误类型。这是一项采用根本原因分析方法的描述性研究，其中对先前已有调查的数据进行了二次分析。在该研究中，护理人员在用药准备和给药过程中识别出74起用药错误。剂量错误（24.3%）、给药时间错误（22.9%）和未授权用药错误（13.5%）最为常见。因此，识别出了用药错误，并进行了根本原因分析，从而确定了导致错误发生的多个因素。还提出了预防错误的策略和建议。
