Errors involving medication exchange in the process of dispensing in a hospital: which classes of medication are involved?
DOI:
https://doi.org/10.11606/issn.1679-9836.v103i1e-181342Keywords:
Medication errors, Hospital, High-Alert Medication Error, Look-Alike Sound-Alike Drug Substitution ErrorsAbstract
Errors can occur in the process of prescription, dispensing and administration of the medication. One of these errors occurs when the medications are exchanged at the time of dispensing and, thus, there may be a failure in treatment and/ or risk to the patient. The purpose of this study is to identify the main classes of drugs involved in this type of error. For this study, the error record was used, which consists of the notifications from the period 01/12/2009 to 07/14/2019 of a medium-sized hospital of Minas Gerais, and each medication of these errors were classified according to the anatomical-therapeutic-chemical class. Among the total errors (N= 3937) reported by the three pharmacies in the hospital, 755 (19.18%) errors related to the exchange of medicines were observed, which the “Look-Alike” and “Sound-Alike” corresponded to 303 errors (40.13%), anti-infectious agents to 238 errors (31.52%) and high-alert medication to 189 errors (25.03%), representing the most medication errors of this study. In this way, the automation of the service and the continuing education of health care professionals are one of the alternatives to avoid these errors and promote favorable clinical outcomes for patients.
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Copyright (c) 2024 Jéssica Octávia de Morais, Jordânia Ferreira Martins, Lays Cássia Santos Duarte Melo, Lorena Aguiar Soares, Cristina Sanches, André Oliveira Baldoni, Mariana Linhares Pereira
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