The medication preparation and administration process: problem identification in order to propose improvements and prevent medication errors

Authors

  • Adriana Inocenti Miasso Universidade de São Paulo; Escola de Enfermagem de Ribeirão Preto
  • Ana Elisa Bauer de Camargo Silva Universidade Federal de Goiás; Faculdade de Enfermagem
  • Silvia Helena de Bortoli Cassiani Universidade de São Paulo; Escola de Enfermagem de Ribeirão Preto
  • Cris Renata Grou Universidade de São Paulo; Faculdade de Medicina de Ribeirão Preto; Hospital das Clínicas
  • Regina Célia de Oliveira Universidade de Pernambuco; Faculdade de Enfermagem Nossa Senhora das Graças
  • Flávio Trevisan Fakih Universidade Federal de São Paulo; Hospital São Paulo

DOI:

https://doi.org/10.1590/S0104-11692006000300008

Keywords:

medication errors, medication systems, hospital administration, nursing

Abstract

This exploratory study analyzed the medication preparation and administration process in medical-clinical units at four Brazilian hospitals located in the Southeast, Central-West and Northeast, identified problems that can contribute to the occurrence of medication errors and proposed improvement measures. Data were collected through non-participant and direct observation of nursing professionals' activities during one week. The results revealed the following main problems: the environment in Hospital B; preparation errors related to technique and anticipated medication preparation in C and D; technical, communication and patient identification mistakes in Hospital A. Suggestions to achieve greater quality and safety in patient care include the constitution of a multidisciplinary commission to evaluate the system, nursing discussion groups, environmental improvements, permanent courses and training and actual presence of a nurse during the process.

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Published

2006-06-01

Issue

Vol. 14 No. 3 (2006)

Section

Original Articles

License

RLAE’s authorship concept is based on the substantial contribution by each of the individuals listed as authors, mainly in terms of conceiving and planning the research project, collecting or analyzing and interpreting data, writing and critical review. Indication of authors’ names under the article title is limited to six. If more, authors are listed on the online submission form under Acknowledgements. The possibility of including more than six authors will only be examined on multicenter studies, considering the explanations presented by the authors.
Including names of authors whose contribution does not fit into the above criteria cannot be justified. Those names can be included in the Acknowledgements section.
 Authors are fully responsible for the concepts disseminated in their manuscripts, which do not necessarily reflect the editors’ and editorial board’s opinion.

 

How to Cite

The medication preparation and administration process: problem identification in order to propose improvements and prevent medication errors. (2006). Revista Latino-Americana De Enfermagem, 14(3), 354-363. https://doi.org/10.1590/S0104-11692006000300008