Prevenção de erros de medicação em ambiente hospitalar na perspectiva da enfermagem

Abstract

Medication errors constitute a serious threat to the health of individuals, representing a great challenge to health professionals and institutions. Recognizing aspects that collaborate with errors prevention, in the sense of assuring assistance that is safe and free from harm to the patient, is primordial, especially in hospital services. Given the relevance of this theme, the present study aimed to characterize the aspects that contribute and hinder the prevention of medication errors in the hospital environment, under nursing perspective. It was a descriptive-exploratory research, with data qualitative approach. The sample was composed by 19 nurses and nurse technicians at a universitary hospital in São Paulo state countryside. Data collection and analysis were guided by the Critical Incident Technique (CIT), which is a strategy of human behavior analysis as subside for the resolution of practical problems. Data collection was performed through individual interviews, guided by a semi-structured script with questions and transcribed by the researcher herself. Analysis followed the steps proposed by CIT, systematizing the data on a Excel spreadsheet in order to identify the Situations, Behaviors and Consequences of the Critical Incidents. 35 Situations, 72 Behaviors and 35 Consequences were extracted from the interview, which allowed the identification of frailties and potentialities in the services. Among the frailties, it is possible to highlight: inconsistencies in medical prescription; lack of attention and hurry of the professionals involved in the medication process; inadequate number of people, which results in work overload; work pace intensification and professional’s illness; non observance of the nine rights of medication administration (right patient, right medication, right route, right time, right dose, right documentation, right orientation, right way and right response); communication problems; patients with the same name in the same nursery; lack of training; verbal prescription; prescriptors handwriting and ineffective orientation. Among the potentialities, it was possible to identify: incident notice to the nurse; not administering medication when one is not sure; applying the nine rights of medication administration; effective communication among assistential teams; interprofessional work; use of electronic prescription; error studying as a way of reincidence prevention; care planning; nurses orientation and training. The referred strategies were: use of nine rights of medication administration in everyday work, reading the medical prescription more than once, asking whenever there are questions about the prescription, preparing medication with prescription in hands, signed and stamped by the doctor, avoiding verbal prescription, informing the patient about the medication which will be administered, medication double-checking, following the institution’s protocols and confirming the patient’s clinical condition with the prescription indication. This study identified nursing as the last barrier to prevention of medication error, so it must be trained to perform an early identification of the error possibility to the patient.