Causes of Medication Administration Errors in a University Hospital in Brazil
Author(s)
Assunção-Costa L1, Sampaio B1, Machado JFF2, Pinto C1, de Souza LEPF3
1Federal University of Bahia, Salvador, BA, Brazil, 2Instituto Nacional de Assistência Farmacêutica e Farmacoeconomia, Salvador, Brazil, 3Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
Presentation Documents
OBJECTIVES:
To identify the causes of medication administration errors (MAE) in a University Hospital.METHODS:
Observational study carried out using the technique of direct observation of medication administration. Data were collected between January and February, 2019, and the analysis and classification of causes were collected between August and October, 2019. Each observed dose was compared with the dose prescribed. In case of discrepancy, the error was described and categorized. Prescribed and unadministered doses were categorized as omission errors. From the identified errors, there was detailing of the causes. For each error, the latent condition or active failure was classified into violations or slips, forgetfulness or mistakes. In addition to these categories, subclassifications for the occurrence of errors were defined, namely: overload, supervision, individual factor, patient-related factors, communication and other factors.RESULTS:
Overall 564 doses were observed, and 199 (35.28%) MAE were identified. Of these, 193 (96.98%) were attributed to active failures that are divided into violations (101; 52.33%), slips/forgetfulness (95; 49.22%) and mistakes (5; 2.59%). Six (3.02%) errors were classified as latent failures. More than one classification has been assigned to some MAE. Failure to follow the manual dilution was predominant in technical errors caused by violation. As for slips/forgettings, the following subclassifications were attributed: 51 (53.68%) errors attributed to overload, 18 (18.95%) attributed to individual factors, 11 (11.58%) attributed to other factors (doses whose information collected was not sufficient to investigate the causes), 10 (10.53%) attributed to factors related to the patient, 5 (5.26%) attributed to inadequate supervision and 1 (1.05%) attributed to communication. Among the errors classified as mistakes, 4 (80%) were attributed to individual factors and 1 (20%) to other factors.CONCLUSIONS:
The analysis of the causes that give rise to MAE may allow the design of actions aimed to prevent and minimize risks for patients and for the institution.Conference/Value in Health Info
2022-11, ISPOR Europe 2022, Vienna, Austria
Value in Health, Volume 25, Issue 12S (December 2022)
Code
EPH111
Topic
Epidemiology & Public Health
Topic Subcategory
Safety & Pharmacoepidemiology
Disease
SDC: Cardiovascular Disorders (including MI, Stroke, Circulatory), SDC: Gastrointestinal Disorders, SDC: Musculoskeletal Disorders (Arthritis, Bone Disorders, Osteoporosis, Other Musculoskeletal), SDC: Neurological Disorders