Evaluation of medication errors at a university hospital*ABSTRACT The objectives of this study were to iden- tify and analyze the types of medication errors observed in doses prepared and ad- ministered differently from those pre- scribed.

Evaluation of medication errors at a university hospital*ABSTRACT The objectives of this study were to iden- tify and analyze the types of medication errors observed in doses prepared and ad- ministered differently from those pre- scribed.

137Rev Esc Enferm USP2010; 44(1):137-44www.ee.usp.br/reeusp/ Root cause analysis: evaluation of medication errors at a university hospital Teixeira TCA, Cassiani SHDB

Root cause analysis: evaluation of medication errors at a university hospital*

ANÁLISE DE CAUSA RAIZ: AVALIAÇÃO DE ERROS DE MEDICAÇÃO EM UM HOSPITAL UNIVERSITÁRIO

ANÁLISIS DE CAUSA RAÍZ: EVALUACIÓN DE ERRORES DE MEDICACIÓN EN UN HOSPITAL UNIVERSITARIO

* Part of the thesis, “Análise de causa raiz: avaliação de erros de medicação em uma unidade de clínica médica de um hospital universitário”, University of São Paulo at Ribeirão Preto College of Nursing, 2007. 1 RN. MSc in Fundamental Nursing at University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil. thalytacat@hotmail.com 2 RN. Full Professor at General and Specialized Nursing Department, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil. shbcassi@eerp.usp.br

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Received: 09/06/2007 Approved: 03/11/2009

Portuguese / English: www.scielo.br/reeusp

RESUMO Os objetivos deste estudo foram identifi- car e analisar os tipos de erros de medica- ção observados nas doses de medicamen- tos que foram preparadas e administradas de forma diferente daquelas prescritas. Es- tudo descritivo, utilizando o método de análise de causa raiz, que realizou uma aná- lise secundária de dados de um estudo já existente. No estudo, 74 erros de medica- ção foram identificados, durante o preparo e a administração de medicamentos pela equipe de enfermagem. Erros de dose (24,3%), erros de horário (22,9%) e medi- camentos não autorizados (13,5%) foram os mais frequentes. Assim, a análise de causa raiz foi realizada, identificando múltiplos fatores que contribuíram para a ocorrência dos erros, e estratégias e recomendações foram apresentadas para evitá-los.

DESCRITORES Sistema de medicação no hospital. Erros de medicação. Gerenciamento de segurança. Controle de risco. Enfermagem.

Thalyta Cardoso Alux Teixeira1, Silvia Helena De Bortoli Cassiani2

ABSTRACT The objectives of this study were to iden- tify and analyze the types of medication errors observed in doses prepared and ad- ministered differently from those pre- scribed. It is a descriptive study using the root cause analysis method, in which a sec- ondary analysis of data from a previously existing investigation was performed. In the study, 74 medication errors were identified during medication preparation and admin- istration by the nursing staff. Dose errors (24.3%), schedule errors (22.9%) and unau- thorized medication administration errors (13.5%) were the most frequent. Hence, medication errors were identified, and root cause analysis was performed, leading to the identification of multiple factors that contributed to error occurrence. Strategies and recommendations were presented for the prevention of errors.

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