Description of medication errors detected at a drug information centre in Southern Brazil
Objective: To identify and describe actual or potential medication errors related to drug information inquiries made by staff members of a teaching hospital to a Drug Information Centre from January 2012 to December 2013.
Methods: Data were collected from the records of inquiries made by health care professionals to the Drug Information Centre throughout this period.
Results: During the study period, the Drug Information Centre received 3,500 inquiries. Of these, 114 inquiries had medication errors. Most errors were related to prescribing, preparation, and administration and were classified according to severity as category B (57%) (potential errors) and categories C (26.3%) and D (15.8%) (actual errors that did not result in harm to the patient). Error causes included overdose (13.2%), wrong route of administration (11.4%), inadequate drug storage (11.4%), and wrong dosage form (8.8%). The drugs most frequently involved in errors were vitamin K (4.4%), vancomycin (3.5%), and meropenem (3.5%).
Conclusion: In this study, it was not possible to measure the reduction in error rate involving medication use because of the lack of previous data on this process in the institution. However, our findings indicate that the Drug Information Centre may be used as a strategy to seek improvements in processes involving medication use.
2. Ferracini FT, Mendes W, Filho B, Farmácia clinica: segurança na prática hospitalar. São Paulo: Atheneu; 2011.
3. Rede brasileira de centros e serviços de informação sobre medicamentos. Available at: http://rebracim.webnode.com.br/membros-rebracim/ (Accessed 1 March 2014).
4. Silva AEBC, Cassiani SHB. Erros de medicação em hospital universitário: tipo, causas, sugestões e providências. Available at: http://www.scielo.br/scielo.php?pid=S0034-71672004000600007&script=sci_arttext (Accessed 1 March 2014).
5. Miasso AI, Grou CR, Cassiani SHB, Silva AEBC, Fakih FT. Erros de medicação: tipos, fatores causais e providências tomadas em quatro hospitais brasileiros. Disponível em: www.scielo.br/pdf/reeusp/v40n4/v40n4a10.pdf (Accessed 1 March 2014).
6. National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP). About medication errors. Available at: http://www.nccmerp.org/aboutMedErrors.html (Accessed 1 April 2014).
7. Lacasa C. Accidentes con medicamentos, conceptos, clasificacion y métodos de deteccion. In: Lacasa C, Humet C, Cot R. Errores de Medicacion – Prevencion, Diagnostico y Tratamiento. Barcelona: EASO; 2001.
8. RDC 36 DE 2013. Available at: http://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2013/rdc0036_25_07_2013.html (Accessed 1 April 2014).
9. Portaria nº 2.647, de 4 de novembro de 2013. Available at: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt2647_04_11_2013.html (Accessed 1 April 2014].
10. Cavallini ME, Bisson MP. Farmácia hospitalar: um enfoque em sistemas de saúde, 1ed. São Paulo: Manole; 2002.
11. American Society of Health-System Pharmacists (ASHP). Guideline on preventing medication errors in hospitals. Am J Hosp Pharm. 1993;50(2):305-314.
12. National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP). About medication errors. Available at: http://www.nccmerp.org/medErrorCatIndex.html (Accessed 1 November 2011).
13. Institute for Safe Medication Practices (ISMP). ISMP’s list of high-alert medications, 2012. Available at: http://www.ismp.org/Tools/institutionalhighAlert.asp (Acessed 1 October 2012).
14. Fahimi F, Ariapanah P, Faizi M, Shafaghi B, Namdar R, Ardakani MT. Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: An observational study. Aust Crit Care. 2008;21(2):110-116. doi: 10.1016/j.aucc.2007.10.004
15. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington: National Academy of the Institute of Medicine: 1999.
16. Protocolo coordenado pelo Ministério da Saúde e ANVISA em parceria com FIOCRUZ e FHEMIG (Anexo 3: Protocolo de segurança na prescrição, uso e administração de medicamentos). Available at: http://www.anvisa.gov.br/hotsite/segurancadopaciente/documentos/julho/Protocolo%20Identifica%C3%A7%C3%A3o%20do%20Paciente.pdf (Acessed 1 June 2014).
17. Carvalho VT, Cassiani SHB. [Medication errors and consequences for nursing professionals and clients: an exploratory study]. Rev Latino-Am Enferm. 2002;10(4):523-529.
18. Dalmolin GRS; Rotta ET; Goldim JR. Medication errors: classification of seriousness, type, and of medications involved in the reports from a University Teaching Hospital. Braz J Pharm Sci. 2013;49(4):793-802.
19. Walsh KE, Kaushal R, Chessare JB.How to avoid paediatric medication errors: a user's guide to the literature. Arch Dis Child. 2005;90(7):698-702.
20. American Society of Consultant Pharmacists (ASCP). Guidelines on preventing medication errors in pharmacies and long-term care facilities through reporting and evaluation. Available at: http://www.ascp.com/public/pr/guidelines/medication (Acessed 1 June 2006).
21. Kopp BJ, Erstad BL, Allen ME, Theodorou AA, Priestley G. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit Care Med. 2006;34(2):415-425.
22. Chapuis C, Roustit M, Bal G, Schwebel C, Pansu P, David-Tchouda S, Foroni L, Calop J, Timsit JF, Allenet B, Bosson JL, Bedouch P. Automated drug dispensing system reduces medication errors in an intensive care setting. Crit Care Med. 2010;38(12):2275-2281. doi: 10.1097/CCM.0b013e3181f8569b
23. Salazar N; Jirón M; Escobar L, Tobar E, Romero C. [Prospective assessment of medication errors in critically ill patients in a university hospital]. Rev Med Chile 2011;139(11):1458-1464.
24. Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit. J Perinatol. 2010;30(7):459-468. doi: 10.1038/jp.2009.186
25. Silva Md, Rosa MB, Franklin BD, Reis AM, Anchieta LM, Mota JA. Concomitant prescribing and dispensing errors at a Brazilian hospital: a descriptive study. Clinics (Sao Paulo). 2011;66(10):1691-1697.
The authors hereby transfer, assign, or otherwise convey to Pharmacy Practice: (1) the right to grant permission to republish or reprint the stated material, in whole or in part, without a fee; (2) the right to print pr epublish copies for free distribution or sale; and (3) the right to republish the stated material in any format (electronic or printed). In addition, the undersigned affirms that the article described above has not previously been published, in whole or part, is not subject to copyright or other rights except by the author(s), and has not been submitted for publication elsewhere, except as communicated in writing to Pharmacy Practice with this document.
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License (CC-BY-NC-ND) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.