Castro-González LV, Martínez-Contreras AM, Caro VJ, Barreras-Serrano A, Dautt-Silva J

Language: Spanish
References: 27
Page: 751-758
PDF size: 208.95 Kb.

ABSTRACT

Background: The frequency of presentation of medication errors is worrisome for any health institution, because they can harm the patient irreversibly.
Objective: To determine the frequency of medication errors in hospitalized patients of Regional Specialty Hospital (RSH) No. 30.
Material and Method: Consecutive cross-sectional study done in patients with an indication of three or more medications, hospitalized in the Internal Medicine service at the RSH No. 30 of the Mexican Social Security Institute, from January to March 2017. Medication errors were classified according to the Joint Commission on Accreditation of Healthcare Organizations, and severity was categorized using the National Coordinating Council for Medication Error Reporting and Prevention scale.
Results: Medication errors were present in 68.1% (n = 265) cases, the most frequently implicated process was administration error in 34.8%, 25.4% in prescription, 21% in dispensation and 18.8% from transcription. According to severity, 55% presented error without damage and 12.3% error with damage.
Conclusions: The frequency of medication errors is high; it is therefore necessary to strengthen and implement security barriers in this process in order to diminish the harm risk for patients.

REFERENCES

1. NCC MERP. (2001). About Medication Errors. [Internet] Disponible en: https://www.nccmerp.org/about-medicationerrors [citado 24 Jul 2019].

2. Navarro P, Arnal D. Errores de medicación: un reto para la anestesiología. Rev Esp Anestesiol Reanim 2017; 64 (9): 487-489. DOI: 10.1016/j.redar.2017.05.002

3. Kee K, Char C, Yip A. A review on interventions to reduce medication discrepancies or errors in primary or ambulatory care setting during care transition from hospital to primary care. J Family Med Prim Care 2018; 7 (3): 501-506. doi: 10.4103/jfmpc.jfmpc_196_17

4. Cohen M, Smetzer J, Vaida A. ASHP guidelines on preventing medication errors in hospitals: Advancing medication safety to the next level. Am J Health Syst Pharm 2018; 75 (19): 1444-1445. doi: 10.2146/ajhp180283

5. Del Rey E, Estrada L. Errores de medicación en pacientes del Hospital Regional Lic. Adolfo López Mateos del ISSSTE. Med Int Méx 2014; 30: 641-650.

6. NCC MERP. (2001). Index for Categorizing Medication Errors Algorithm. [Internet] Disponible en: https://www. nccmerp.org/sites/default/files/algorColor2001-06-12.pdf [citado 24 Jul 2019]

7. Sánchez CJ. Gestión de notificaciones de errores de medicación por entidades regulatorias. Rev Colomb Enferm 2015; 10 (10): 16-26.

8. Barker K, McConnell W. The problems of detecting medication errors in hospitals. Am J Hosp Pharm 1962; 19 (8): 360-369.

9. Billstein M, Carrillo J, Cassano A, Moline K, Robertson J. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm 2018; 75: 1493-1517. doi: 10.2146/ajhp170811

10. Lu M, Yu S, Chen I, Wang K, Wu H, Tang F. Nurses’ knowledge of high-alert medications: a randomized controlled trial. Nurse Education Today 2013; 33 (1): 24-30. doi: 10.1016/j. nedt.2011.11.018

11. Gómez J, Bartolomé A, García S, Puebla G, Santa J, Marzal J, et al. Errores de medicación y etiquetado de las jeringas. Rev Esp de Anestesiol Reanim 2013; 60 (1): 27-33. DOI: 10.1016/S0034-9356(13)70007-0

12. Ayani N, Sakuma M, Morimoto T, Kikuchi T, Watanabe K, Narumoto J, et al. The epidemiology of adverse drug events and medication errors among psychiatric inpatients in Japan: the JADE study. BMC Psychiatry 2016; 16 (1): 303. doi: 10.1186/s12888-016-1009-0

13. Riaz MK, Riaz M, Latif A. Medication errors and strategies for their prevention. Pak J Pharm Sci 2017; 30 (3): 921-928.

14. Sada O, Melkie A, Shibeshi W. Medication prescribing errors in the medical intensive care unit of Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. BMC Res Notes. 2015; 8 (1): 1-7. doi: 10.1186/s13104-015-1435-y

15. Merino P, Martín M, Alonso A, Gutiérrez I, Álvarez J, Becerril F. Errores de medicación en los servicios de Medicina Intensiva españoles. Med Intensiva 2013; 37 (6): 391-399. DOI: 10.1016/j.medin.2012.11.002

16. Castro A, Sotomayor J, Sepúlveda Y, Mena S. Experiencia de un sistema de reporte de errores de medicación en un hospital docente. Enferm Glob. 2014; 13 (33): 202-212.

17. Rivera N, Moreno R, Escobar S. Prevalencia de errores en la utilización de medicamentos en pacientes de alto riesgo farmacológico y análisis de sus potenciales causas en una entidad hospitalaria. Enferm Glob 2013; 12 (32): 171-184.

18. Härkänen M, Ahonen J, Kervinen M, Turunen H, Vehviläinen K. The factors associated with medication errors in adult medical and surgical inpatients: a direct observation approach with medication record reviews. Scand J Caring Sci 2015; 29 (2): 297-306. doi: 10.1111/scs.12163

19. Santell J, Hicks R, McMeekin J, Cousins D. Medication errors: experience of the United States Pharmacopeia (USP) MEDMARX reporting system. J Clin Pharmacol. 2003; 43 (7): 760-767. DOI: 10.1177/0091270003043007011

20. Da Silva B, Krishnamurthy M. The alarming reality of medication error: a patient case and review of Pennsylvania and National data. J Community Hosp Intern Med Perspect 2016; 6 (4): 31758. doi: 10.3402/jchimp.v6.31758

21. Escobar F, Marques T, Alux T, Sabóia M, Bauer A, De Bortoli S. Administração de medicamentos, em vias diferentes das prescritas, relacionada à prescrição médica. Rev Latinoam Enfermagem 2011; 19 (1): 1-7.

22. Machado J, Moreno P, Moncada J. Hospital medication errors in a pharmacovigilance system in Colombia. Farm Hosp 2015; 39 (6): 338-343. doi: 10.7399/ fh.2015.39.6.8899

23. Saucedo A, Serrano F, Flores V, Morales E, Santos A. Errores frecuentes en la administración de medicamentos intravenosos en pediatría. Rev Enferm Inst Mex Seguro Soc. 2008; 16(1): 19-26.

24. Rendón M, Heyser S, Reyes N. Índice de anotaciones médicas equivocadas. Efecto de la periodicidad en la actualización. Rev Med IMSS. 2002; 40 (4): 285-291.

25. Nguyen H, Nguyen T, Van Den E, Haaijer F, Taxis K. Medication errors in Vietnamese hospitals: Prevalence, potential outcome and associated factors. PLoS One. 2015; 10 (9): e0138284. doi: 10.1371/journal.pone.0138284

26. Patel N, Desai M, Shah S, Patel P, Gandhi A. A study of medication errors in a tertiary care hospital. Perspect Clin Res 2016; 7 (4): 168-173. doi: 10.4103/2229-3485.192039

27. Kohn L, Corrigan J, Donaldson M. To err is human: Building a safer health system. Washington: National Academy Press, 2000; 60-63.