Prescrição eletrônica: frequência e gravidade dos erros de medicação

Abstract

Objective: To assess the frequency and severity of errors in prescriptions involving high-alert medications (heparin and potassium chloride for injection concentrate), before and after the introduction of computer order entry system (CPOE). Methods: this is a retrospective study that compared prescription errors in manual/pre- -typed prescriptions in 2007 (Phase 1) and in CPOE prescriptions in 2014 (Phase 2). A total of 1.028 prescriptions were analyzed in two high complexity hospitals of Belo Horizonte. Results: An increase of 25% in the frequency of errors in hospital 1 was observed after the intervention (p<0.001). In contrast, a decrease of 85% in the frequency of errors was observed in the hospital 2 (p<0.001). For the potassium chloride, the error rate remained the same in hospital 1 (p>0.05). In the hospital 2, a significant decrease in phase 2 after the intervention was detected. There was reduction in the severity of the errors with the heparin (p<0.001), while in the prescription of potassium chloride, there were no differences (p> 0.05). Conclusions: The severity of medication errors after the introduction of CPOE was affected differently in the two hospitals demonstrating need for careful observation when the prescription system is modified. During and after the implementation of new CPOE technology, the possible introduction of new types of errors and their causes should be monitored in order to adopt preventive measures for such incidents.