Incidentes críticos relacionados aos eventos adversos a medicamentos em uma unidade de clínica médica de um hospital público do Estado do Amazonas / Critical incidents related to adverse drug events at a medical clinical unit in a public hospital of the state of Amazonas

AUTOR(ES)
DATA DE PUBLICAÇÃO

2010

RESUMO

Adverse drug events are common and will probably occur in any system, however, it is essential to identify their causes and try to minimize the risks to patientssafety. This descriptive study aimed to analyze adverse drug events at a public hospital in the state of Amazonas, based on the reports of the nursing team. The goal was to propose strategies for the institution to optimize the medication system for patient safety. The Critical Incident Technique guided the methodological procedures, carried out with 15 nurses, 09 nursing auxiliaries and 44 nursing technicians from a teaching hospital in Manaus, state of Amazonas. Data analysis consisted of identifying and grouping situations, behaviors and consequences. Most of the interviewed professionals were female (89.7%) from the age group of 31 to 35 (30.9%) years. Results of the studies were grouped and categorized into 47 situations, corresponding to nine types of medication errors. Of the types of errors identified by the nursing team, dilution errors (23.4%), dosing errors (14.9%), unauthorized medication (14.9%), wrong administration route (10.6%) and mistaken patient (8.5%) were the most frequent. The categories of behavior were distributed according to the perception and communication of error (36) and among the consequences identified in the study (103), of which 47 were related to patients and 56 to nursing professionals. The results indicate the need for immediate initiatives that minimize these situations and prevent the occurrence of future adverse drug events.

ASSUNTO(S)

adverse drug event enfermagem evento adverso a medicamento medicamentos nursing pharmaceutical preparations

ACESSO AO ARTIGO

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