Department of Medicine, School of Pharmacy, Federal University of Bahia, Salvador, Bahia, Brazil.
Department of Pharmacy, University Hospital Professor Edgard Santos, Salvador, Bahia, Brazil.
PLoS One. 2022 Aug 4;17(8):e0272123. doi: 10.1371/journal.pone.0272123. eCollection 2022.
This study systematically reviewed studies to determine the frequency and nature of medication administration errors in Latin American hospitals.
We systematically searched the medical literature of seven electronic databases to identify studies on medication administration errors in Latin American hospitals using the direct observation method. Studies published in English, Spanish, or Portuguese between 1946 and March 2021 were included. A total of 10 studies conducted at 22 hospitals were included in the review. Nursing professionals were the most frequently observed during medication administration and were observers in four of the ten included studies. Total number of error opportunities was used as a parameter to calculate error rates. The administration error rate had a median of 32% (interquartile range 16%-35.8%) with high variability in the described frequencies (9%-64%). Excluding time errors, the median error rate was 9.7% (interquartile range 7.4%-29.5%). Four different definitions of medication errors were used in these studies. The most frequently observed errors were time, dose, and omission. Only four studies described the therapeutic classes or groups involved in the errors, with systemic anti-infectives being the most reported. None of the studies assessed the severity or outcome of the errors. The assessment of the overall risk bias revealed that one study had low risk, three had moderate risk, and three had high risk. In the assessment of the exploratory, observational, and before-after studies, two were classified as having fair quality and one as having poor quality.
The administration error rate in Latin America was high, even when time errors were excluded. The variation observed in the frequencies can be explained by the different contexts in which the study was conducted. Future research using direct observation techniques is necessary to more accurately estimate the nature and severity of medication administration errors.
本研究系统回顾了拉丁美洲医院用药错误的发生频率和性质。
我们系统地检索了七个电子数据库中的医学文献，以确定使用直接观察法在拉丁美洲医院进行的用药错误研究。纳入了发表于 1946 年至 2021 年 3 月间的英文、西班牙文或葡萄牙文文献。共纳入了 10 项在 22 家医院进行的研究。在用药过程中，护理人员是最常被观察到的，在纳入的 10 项研究中有 4 项是护理人员作为观察者。总错误机会数被用作计算错误率的参数。给药错误率的中位数为 32%（四分位距 16%-35.8%），描述的频率差异很大（9%-64%）。排除时间错误后，错误率中位数为 9.7%（四分位距 7.4%-29.5%）。这四项研究采用了四种不同的用药错误定义。最常观察到的错误是时间、剂量和遗漏。仅有四项研究描述了涉及的治疗类别或药物组，其中全身抗感染药物的报道最多。没有研究评估错误的严重程度或结果。对整体风险偏倚的评估显示，一项研究为低风险，三项为中风险，三项为高风险。在对探索性、观察性和前后对照研究的评估中，有两项被归类为具有良好质量，一项为较差质量。
即使排除时间错误，拉丁美洲的给药错误率仍很高。观察到的频率差异可以用研究进行的不同背景来解释。未来需要使用直接观察技术进行研究，以更准确地估计用药错误的性质和严重程度。
