Graduate Program in Health Sciences, Faculty of Medicine, Federal University of Uberlândia, Uberlândia, MG, Brazil.
Hospital Pharmacy Department, University Hospital, Federal University of Uberlândia, Uberlândia, MG, Brazil.
PLoS One. 2023 Apr 5;18(4):e0284071. doi: 10.1371/journal.pone.0284071. eCollection 2023.
In university hospital settings most prescriptions are written by junior doctors, who are more likely to make prescribing errors than experienced doctors. Prescribing errors can cause serious harm to patients and drug harm differs among low, middle and high-income countries. In Brazil, few studies have investigated the causes of these errors. Our aim was to explore medication prescribing errors in a teaching hospital, their causes, and underlying factors from the perspective of junior doctors.
Qualitative, descriptive and exploratory study that used a semi-structured individual interview with questions related to the planning and execution of prescriptions. It was conducted with 34 junior doctors who graduated from twelve different universities located in six Brazilian states. The data were analyzed according to the Reason's Accident Causation model.
Among the 105 errors reported, medication omission stood out. Most errors resulted from unsafe acts during execution, followed by mistakes and violations. Many errors reached the patients; unsafe acts of rule violations and slips accounted for the majority. Work overload and time pressure were the most frequently reported causes. Difficulties faced by the National Health System and organizational problems were identified as latent conditions.
The results reaffirm international findings about the severity of prescribing errors and the multifactorial aspect of their causes. Unlike other studies, we found a large number of violations, which, from the interviewees' perspectives, are related to socioeconomic and cultural patterns. The violations were not seen or mentioned by the interviewees as violations, but as difficulties in accomplishing their tasks on time. Knowing these patterns and perspectives is important for implementing strategies to improve the safety of both patients and professionals involved in the medication process. It is suggested that the exploitation culture of junior doctors' work be discouraged and that their training be improved and prioritized.
在大学医院环境中，大多数处方由初级医生开具，他们比经验丰富的医生更容易出现处方错误。处方错误可能对患者造成严重伤害，且药物伤害在低收入、中等收入和高收入国家之间存在差异。在巴西，很少有研究调查这些错误的原因。我们的目的是从初级医生的角度探讨教学医院的药物处方错误、其原因和潜在因素。
这是一项定性、描述性和探索性研究，采用半结构化个人访谈，问题涉及处方的规划和执行。研究对象为来自巴西六个州的十二所不同大学的 34 名初级医生。根据 Reason 的事故因果模型分析数据。
在所报告的 105 个错误中，药物遗漏尤为突出。大多数错误是由于执行过程中的不安全行为引起的，其次是错误和违规行为。许多错误已到达患者，不安全的违规行为和失误占大多数。工作负荷过重和时间压力是最常报告的原因。国家卫生系统面临的困难和组织问题被确定为潜在条件。
研究结果再次证实了国际上关于处方错误严重性以及其原因多因素性的发现。与其他研究不同，我们发现了大量的违规行为，从受访者的角度来看，这些违规行为与社会经济和文化模式有关。受访者没有将这些违规行为视为违规行为，而是视为按时完成任务的困难。了解这些模式和观点对于实施策略以提高患者和参与药物治疗过程的专业人员的安全性非常重要。建议遏制初级医生工作的剥削文化，并优先改进和重视他们的培训。
