Escola Paulista de Enfermagem, Universidade Federal de São Paulo, Brazil.
Cancer Nurs. 2011 Sep-Oct;34(5):393-400. doi: 10.1097/NCC.0b013e3182064a6a.
Considering all sources of errors that may occur during healthcare, medication errors are the most common and also the most frequent cause of adverse events.
The objective of the study was to describe the medication errors reported in a pediatric intensive care unit for oncologic patients.
This is a descriptive and exploratory study. The errors were reported by the professionals involved in the medication system in a medication error report form developed for the study.
The sample consisted of 110 medication errors reported on 71 forms. The omission error was the most common error type reported (22.7%), followed by administration error (18.2%). No harm to patients was reported in 83.1% of the notifications.
The analysis of the110 medication errors provides evidence of the context of their occurrence and the need to implement measures that can prevent or intercept these errors.
In an institution without adverse events report and a formal system to patient safety analysis, the implementation of a local nonpunitive approach to medication errors notification represented an important tool to patient safety promotion.
考虑到医疗保健过程中可能出现的所有错误来源，用药错误是最常见也是最频繁的不良事件原因。
本研究旨在描述肿瘤科患儿重症监护病房报告的用药错误。
这是一项描述性和探索性研究。用药错误由参与用药系统的专业人员在为研究制定的用药错误报告表中报告。
样本由 71 份表格中报告的 110 例用药错误组成。漏用错误是报告最多的错误类型（22.7%），其次是给药错误（18.2%）。83.1%的通知中未报告对患者造成伤害。
对 110 例用药错误的分析提供了其发生背景和实施可预防或拦截这些错误的措施的证据。
在一个没有不良事件报告和正式的患者安全分析系统的机构中，实施对用药错误报告的本地非惩罚性方法是促进患者安全的重要工具。
