2008, Number 4
Medication mistakes detected across incidents report. They contribute to the safe use of medicaments?
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ABSTRACTObjective: To describe the type of incident reports related to medication errors (EM) that were notified by healthcare providers at Hospital Médica Sur. Background: EM are frequently present during prescription and drug administration. It is mandatory to decrease those with harm to patient, even more, ones that carry death or serious harm. Diverse methods have been evaluated for detection, we present our local experience. Methods: Descriptive study from case series collected between June 2007 and July 2008 based on voluntary incident reporting associated to EM. Results: 37 cases were notified by nurses (35.1%), pharmacist (35.1%) and physicians (29.7%). Twenty were adults, 14 geriatric and 3 pediatric patients. Common errors were duplicity in 7/49 cases, wrong drug administration (n= 6), overdosing (n= 5) and wrong drug preparation (n= 3), involving ketorolac in 6 cases, amphotericin B (n= 4), parecoxib (n= 4), heparine (n= 3) and morphine (n= 3). Harm to patient were registered in 13/37 cases and 3 cases were sentinel events. 50% (n= 24) occurred during prescription, 18 during drug administration and orders transcription. Main related factors were human and communication mistakes. Conclusions: EM were similar to diverse sources and commitment to report from health professionals was observed. Prescription errors were more common, but with less serious harm than wrong preparation and transcription. It is long overdue to improve working systems for decreasing their vulnerability and taking care of patient safety.
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