Notificações de erros de medicação na Atenção Primária à Saúde de uma capital brasileira: uma análise na ótica da segurança do paciente

Abstract

The available data on the frequency and impact of medication errors in healthcare settings mostly come from studies covering hospital environments, with scarce information on Primary Health Care (PHC). Medication error reports are crucial tools for identifying flaws in healthcare delivery. In this context, the present study aimed to describe the profile of medication error reports made by PHC professionals in a Brazilian capital city from February 2020 to February 2023. For this purpose, a descriptive, quantitative study was conducted based on a retrospective collection of secondary data from the Medication Error Notification System of the Municipality of Belo Horizonte, known as NOTIMED. Descriptive statistics were adopted in data analysis. The main types of incidents reported were medication dispensing errors (73%), followed by prescription errors (23%) and administration errors (4%). The main classes of drugs related to errors were antihypertensives (15.5%), antidiabetics and oral hypoglycemic agents (9.4%), and anticonvulsants (7.9%). The majority of errors had an outcome of "no harm" (96.3%), 2.6% had mild outcomes, and 1.1% had severe outcomes, including one fatality. The information collection format of NOTIMED had limitations that prevented more complex statistical calculations. Adjustments are recommended to facilitate future analyses. Furthermore, it is recommended that the implementation of a safety culture in PHC becomes a priority on the public health agenda in the municipality. From this perspective, the establishment of effective and active Patient Safety Units in healthcare services emerges as a fundamental strategy to ensure qualified and safe healthcare for users of the services in Belo Horizonte.