Erros de dispensação em hospital universitário: análise e contribuições para o uso seguro de medicamentos

Abstract

The objectives of the present study were to analyze medication dispensing errors in a high-complexity public teaching hospital; to identify errors in the medication dispensing process; to classify dispensing errors by type; to determine the rate of medication dispensing errors; to analyze factors associated with the errors in the medication dispensing process; to analyze prescriptions of potentially dangerous medications; to identify practices adopted for dispensing potentially dangerous medications; and to propose strategies to prevent adverse events. In this study, the authors used medical prescriptions and the respective medication kits for dispensing, and a checklist based on the Protocol of Safety in Prescription, Use, and Administration of Medications of the Brazilian Ministry of Health and the Brazilian Health Regulatory Agency as an instrument for observing dispensing practices. In the first cross-sectional study, the kits were open for verification and identification of possible dispensing errors. Fitted hierarchical regression was used to analyze how the outcome variable, “medication dispensing error”, was influenced by the explanatory variables, and to identify factors associated with dispensing errors. Dispensing errors were found in 236 medications, and varied calculation methods resulted in the following rates: 4.2%, 7.3% and 24.9%. The main errors were related to content, due to quality deviation and omission. In the final regression model, the following variables remained associated with an increased chance of dispensing errors: night shift and presence of sources of interruptions/distraction. In the second cross-sectional study, the prescriptions of potentially dangerous medications were analyzed, and the practices adopted in their dispensing were identified, to propose strategies for the prevention of adverse events. The chi-square non-parametric test of independence was used to evaluate the association between prescriptions with and without potentially dangerous medications and hospitalization units. Over half the prescriptions had two or more potentially dangerous medications and almost all of them were injectable, mainly opioid analgesics, glucose 50% and insulin NPH and regular. The rate of potentially dangerous medications prescribed corresponded to 18.2%. The main practices that posed risks were: collective distribution of potassium chloride and insulin; lack of warning tags; absence of double-checking; and use of sources of interruptions/distraction in 43.9% of the prescriptions. The types of errors and associated factors showed a need for an effective quality program that considers the recommendations made in the protocol of the Brazilian Ministry of Health and the Brazilian Health Regulatory Agency.