Erros de medicação em um hospital de referência de Minas Gerais, 2001

Abstract

Aiming to evaluate the use of drugs and high-risk conditions predisposing to medication errors, there was a cross-sectional study in 4026 prescriptions containing potentially dangerous drugs (MPP) in a public hospital of reference of Minas Gerais, the period August-September 2001. The readability analysis showed that 19.4% of prescriptions were classified as barely legible and illegible, which increases the risk of measurement errors. The type of limitation was classified into three options: handwriting, mixed or pre-typed and evaluated concurrently readability. There's a higher chance of pre-typed prescriptions delivered the best results in terms of readability. There's a higher chance of handwritten prescriptions are illegible or barely legible, increasing the risk of mistakes. Prescription Pre-typed showed the best results in terms of readability. We evaluated the identification of prescribers emphasizing that in 39.70% of the cases it was difficult or impossible to know which was the author of the prescription. The 7.148MPP prescribed were examined in relation to legibility, pharmaceutical form, concentration, route of administration, range and rate of infusion. 3177 discrepancies were observed with a convergence of 89.1% in four types of problems: lack of concentration and placement of the pharmaceutical form, concentration is difficult to read and doubtful. The most frequent discrepancy was a lack of placing the merger with 49.76% of the records. The Intensive Care Unit (ICU), the Intensive Care Unit (ICU) and Neurology were the sectors with the highest number of problems per prescription. It was noted discrepancies in the concentration of five MPP: hiparina, fentanyl, midazolam, nalbuphine and pancuronium. There were 23 prescribing errors with the following MPP: heparin, midazolam, digoxin, fentanyl and nalbuphine