System for the use of medications in patients with high pharmacological risk: Quality challenge
Sistema de utilización de medicamentos en pacientes de alto riesgo farmacológico: Reto de calidad
Article Sidebar
PDF (Español (España))
FLIP
Main Article Content
Abstract
The system of medication use (SUM) is composed of multiple processes where nurses, doctors and pharmacy personnel interact, with the former having the most responsibilities. This study sought to establish the prevalence and possible causes of errors in high-risk pharmacological patients in a highly complex hospital. Method: cross-sectional study with follow-up for three months to SUM, with a total of 318 adults; Compliance was reviewed in formulating, delivering, preparing and administering medications. The data were obtained by observation in the field and review of medical records. Results: the overall prevalence of error for every 100 doses / patients throughout the SUM was 5% or more in 95% of cases. Of the total reported errors, 1.89% came to cause harm to the patient. The morning and weekend shifts, the less than six months' experience of the nursing staff and the hospital stay longer than ten days were situations with greater prevalence. Conclusion: the higher prevalence of errors in patients with high pharmacological risk suggests greater difficulty in the management of medications in these cases. Improvement strategies must be aligned with the institutional context and be specific for this group of patients. Abbreviations: SUM, medication use system.
Downloads
Article Details
References
2. Sullivan C et al. Medication reconciliation in the acute care setting: opportunity and challenge for nursing. Journal of nursing Care Quality, 2005. 20(2):95-98.
3. Telles, filho, Paulo Celso Prado, Cassiani de Bortoli, Silvia Helena. Administración de medicamentos: adquisición de conocimientos y habilidades requeridos por un grupo de enfermeros. Rev. Latino-Am. Enfermagem . 2004, vol.12, n.3, pp. 533-540.
4. Decreto 1011 del 2006 del Ministerio de la Proteccion Social, por el cual se establece el Sistema Obligatorio de Garantía de la Calidad en Salud.
5. Rashad Massoud, Karen Askov, Jolee Reinke, Lynne Miller Franco, Thada Bornstein, Elisa Knebel, y Catherine MacAulay. QA Monograph A Modern Paradigm for Improving Healthcare Quality. Quality Assurance Project (QAP). 2008.
6. Thomas w. Nolan, Lloyd P. Provost. Undesrtanding Variation. Quality Progress, ASQC, Milwaukee, May, 1990, pp. 70-78.
7. Paul E. Plsek, MS. Quality Improvement Methods in Clinical Medicine. Pediatrics Vol. 103, Jan, 1999, pp. 203-213.
8. Thalyta Cardoso, Alux Teixeira, Silvia Helena de Bortoli Casani. Root Analysis: Evaluation of medication Errors at a Untiversity Hospital. Rev Esc Enfermeria USP 2010, 44(1), 136-46.
9. Donald M. Berwick, M.D., M.P.P. Continuous Improvement as an Ideal in Health Care N Engl J Med 1989; 320:53-56 January 5, 1989.
10. María Cristina Baracaldo. Detección de errores en medicación en la administración de medicamentos. Universidad Nacional de Colombia. Revista Colombiana de Ciencias Químico farmacéuticas. Vol 29: 26 – 31. Febrero de 2000.
11. Ak Jha, N Prasopa-Plaizer, l Larizgotia, D W Bates. On Behalf of the Research Priority Setting Working Group of the WHO World Alliance for Patient Safety. Patient safety research: an overviem of the global evidence. Qual Saf Health Care 2010; 19:42-47.
12. Baker GR, Norton PG, Flintoft V, et al, The Canadian Adverse Eventes Study, the incidence of adverse events hospital patients in Canada. CMAJ 2004;170: 1678-86.
13. Miller GC, Britth HC, Valenti L. Adverse drug events in general practice patiens in Australia. Med J Aust 2006;184:321-4.
14. Bates DW, Cullen, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE prevention Study Group. JAMA 1995; 274:29-34.
15. Monica Vila`-de-Muga, MD,* Laura Colom-Ferrer, MD,Þ Mariona GonzalezHerrero, MD,Þ and Carles Luaces-Cubells, MD*. Factors Associated With Medication Errors in the Pediatric Emergency Department. Pediatric Emergency Care & Volume 27, Number 4, April 2011.