Erros de dispensação de medicamentos em unidade pediátrica de umhospital universitário

Abstract

Medication is essential in healthcare. The errors that occur in the medication use process contribute to increase the potential risk of adverse events. The pediatric population is more susceptible to the drug-related adverse effects than adults. Because of their nature and use, some drugs are considered as high-risk medication; the consequences may be severe if they are used erroneously. The purpose of this study was to analyse the frequency and types of prescription-related dispensation errors of one or more high-alert medications. An observational descriptive crosssectional study was undertaken to assess 2,443 copies of prescription order forms at a pediatric unit of a university hospital of the Rede Sentinela/Anvisa (Anvisa Sentinel Network), from 6 October to 4 November 2008. Data gathering tools and definitions of prescription and dispensation errors designed specifically for this study were applied. A selection of 823 errors (33.8%) was made, corresponding to those with one or more prescribed high-alert medications. All 705 prescribed and dispensed high-alert medications among them were analyzed. An analysis of dispensation showed that there were 1,708 errors, of which 769 (45.1%) were content errors, 634(37.1%) were documentation errors, and 305 (17.8%) were labeling errors. Among the dispensation errors in this study, 727 (42.7%) were related with prescription quality, all of which were content errors. These errors may be subdivided as follows: 613 (84.3%) refer to the pharmaceutical form; 63 (8.7%) to the dose; 21 (2.9%) to the interval; 15 (2.1%) to the name of high-alert medications; 11 (1.5%) to theconcentration; 3 (0.4%) to the dilution; and 1 (0.1%) to incompatibility. High-Alert Medications with the highest frequency of prescription and dispensation errors were injected midazolam 5mg/ml and fentanyl 50mcg/ml. Good practices in prescription order form-writing, pharmacist analysis of prescriptions, unit dose dispensation, and a computerized prescription system may minimize or avoid the errors described inthis study and improve the healthcare and safety of pediatric patients.