Erros de dispensação de medicamentos em um hospital público pediátrico

OBJECTIVE: assess the safety of medication dispensing processes through the dispensing error rate. METHOD: Cross-sectional study carried out at a pharmaceutical service of a pediatric hospital in Espírito Santo, Brazil. Data collection was performed between August and September 2006, totaling 2620 prescribed medication doses. Any deviation from the medical prescription in dispensing medication was considered a dispensing error. THE CATEGORIES OF MEDICATION ERRORS WERE: content, labeling, and documentation errors. The dispensing error rate was computed by dividing the number of errors by the total of dispensed doses. RESULTS: From the 300 identified errors, 262 (87.3 %) were content errors. The rate of errors in the labeling and documentation categories was 33 (11%) and 5 (1.7%), respectively. CONCLUSION: The total dispensing error rate was higher than rates reported in international studies. The most frequent category was "content error".OBJETIVO: Evaluar la seguridad en el despacho de medicamentos a través de la determinación de la tasa de errores de despacho. MÉTODOS: Estudio transversal que evaluó 2620 dosis de medicamentos despachados entre agosto y septiembre de 2006 en un servicio de farmacia de un hospital pediátrico del Estado de Espíritu Santo, Brasil. Los errores de despacho fueron definidos como cualquier desvío ocurrido entre lo despachado y lo prescrito en la receta médica. Los errores fueron categorizados en contenido, rótulo y documentación. La tasa de error de despacho fue calculada dividiendo el número de errores total por el número total de dosis despachadas. RESULTADOS: de los 300 errores identificados, 262 (87,3 %) fueron de contenido. En las categorías errores de rótulo la tasa fue de 33 (11%) y 5 (1.7%) en la de errores de documentación. CONCLUSIÓN: la tasa total de errores de despacho fue elevada cuando se compara con la descrita en estudios internacionales. La categoría de error más frecuente fue la de "error de contenido".Avaliar a segurança na dispensação de medicamentos através da determinação da taxa de erros de dispensação constituiu o objetivo deste trabalho. O método utilizado foi o estudo transversal que avaliou 2 620 doses de medicamentos dispensados entre agosto e setembro de 2006, em um serviço de farmácia de um hospital pediátrico do Espírito Santo. Os erros de dispensação foram definidos como qualquer desvio entre o dispensado e o prescrito na receita médica. Os erros foram categorizados em conteúdo, rotulagem e documentação. A taxa de erro de dispensação foi calculada dividindo o número de erros total/total de doses dispensadas. Os resultados mostraram que, dos 300 erros identificados, 262 (87,3%) foram de conteúdo. Nas categorias erros de rotulagem a taxa foi de 33 (11%) e 5 (1,7%) na de erros de documentação. Concluiu-se que a taxa total de erros de dispensação foi elevada quando comparada à descrita em estudos internacionais. A categoria de erro mais freqüente foi a de erro de conteúdo

Medication dispensing errors at a public pediatric hospital

OBJECTIVE: assess the safety of medication dispensing processes through the dispensing error rate. METHOD: Cross-sectional study carried out at a pharmaceutical service of a pediatric hospital in Espírito Santo, Brazil. Data collection was performed between August and September 2006, totaling 2620 prescribed medication doses. Any deviation from the medical prescription in dispensing medication was considered a dispensing error. THE CATEGORIES OF MEDICATION ERRORS WERE: content, labeling, and documentation errors. The dispensing error rate was computed by dividing the number of errors by the total of dispensed doses. RESULTS: From the 300 identified errors, 262 (87.3 %) were content errors. The rate of errors in the labeling and documentation categories was 33 (11%) and 5 (1.7%), respectively. CONCLUSION: The total dispensing error rate was higher than rates reported in international studies. The most frequent category was "content error"

Validation of a method to assess the severity of medication administration errors in Brazil

Introduction Medication errors are frequent and have high economic and social impacts; however, some medication errors are more likely to result in harm than others. Therefore, it is critical to determine their severity. Various tools exist to measure and classify the harm associated with medication errors; although, few have been validated internationally.Methods We validated an existing method for assessing the potential severity of medication administration errors (MAEs) in Brazil. Thirty healthcare professionals (doctors, nurses and pharmacists) from Brazil were invited to score 50 cases of MAEs as in the original UK study, regarding their potential harm to the patient, on a scale from 0 to 10. Sixteen cases with known harmful outcomes were included to assess the validity of the scoring. To assess test–retest reliability, 10 cases (of the 50) were scored twice. Potential sources of variability in scoring were evaluated, including the occasion on which the scores were given, the scorers, their profession and the interactions among these variables. Data were analysed using generalisability theory. A G coefficient of 0.8 or more was considered reliable, and a Bland-Altman analysis was used to assess test–retest reliability.Results To obtain a generalisability coefficient of 0.8, a minimum of three judges would need to score each case with their mean score used as an indicator of severity. The method also appeared to be valid, as the judges’ assessments were largely in line with the outcomes of the 16 cases with known outcomes. The Bland-Altman analysis showed that the distribution was homogeneous above and below the mean difference for doctors, pharmacists and nurses.Conclusion The results of this study demonstrate the reliability and validity of an existing method of scoring the severity of MAEs for use in the Brazilian health system

Validation of a method to assess the severity of medication administration errors in Brazil: a study protocol

Background: Medication errors are frequent and have a high economic and social impact and is critical to know their severity. A variety of tools exist to measure and classify the harms associated with medication errors, but few are internationally validated. Design and methods: It was decided to validate a method proposed by Dean and Barber for assessment of the potential severity of medication administration errors. A number of thirty health care professionals (doctors, nurses and pharmacists) from Brazil will receive an invitation to take part by scoring 50 cases of medication errors gathered from an original UK study regarding their potential harm to the patient on scale 0 to 10. Sixteen cases with known actual harm outcomes will be used to assess the validity of their scoring. By looking at 10 errors (out of the 50 cases) scored twice, reliability shall be assessed; and potential sources of variability in scoring will be evaluated depending on the severity of each of error case, the occasion when the scores were given, the scorer, their profession, and interactions among these variables. Generalizability theory will be used for analysing data. Expected impact of the study for public health: This study was submitted to the evaluation of the Research Ethics Committee of the Complexo Hospitalar Universitário Professor Edgard Santos and approved under no. 3.102.570/2019. This is the first validation of this method for use in Brazil, and will allow researchers to conduct more standardised evaluations of interventions to reduce the impact of medication errors