Tipos e causas de erros de uso de medicamentos em serviços hospitalares de emergência:

uma revisão integrativa

Autores

  • Paola de Camargo Bendinelli Hospital Sírio-Libanês
  • Samanta Lopes Tomaz Hospital Sírio-Libanês

DOI:

https://doi.org/10.54143/jbmede.v3i4.67

Palavras-chave:

Serviço hospitalar de emergência;, Segurança do paciente;, Gestão em saúde

Resumo

 

 O objetivo deste artigo foi identificar as publicações dos últimos 5 anos sobre os tipos e as causas de erros de medicação em serviços hospitalares de emergência. Trata-se de revisão integrativa de literatura. Foram identificados 6.440 artigos, e 15 deles foram selecionados para compor a revisão. Houve predomínio de estudos no ano de 2020, nos Estados Unidos, e com delineamento metodológico transversal. A maior parte das publicações foi realizada em serviços que atendiam a população adulta. Erros de uso de medicamentos acontecem por causas singulares e variantes em serviços hospitalares de emergência. O conhecimento desses fatores é relevante para evitar a ocorrência de erros. A educação continuada exerce papel fundamental na busca por melhorias na qualidade assistencial. O uso de tecnologias e os meios digitais são associados à redução de erros. As instituições devem promover a cultura de segurança do paciente para resultados mais eficazes. 

Referências

World Health Organization (WHO). Medication errors: technical

series on safer primary care. Geneva: WHO; 2016 [cited 2024

Jan 15]. Avialable from: https://www.who.int/publications/i/

item/9789241511643

Brasil. Ministério da Saúde. Fundação Oswaldo Cruz; Agência

Nacional de Vigilância Sanitária. Documento de referência para

o Programa Nacional de Segurança do Paciente. Brasília, DF:

Ministério da Saúde; 2014 [citado 2024 Jan 15]. Disponível

em: https://bvsms.saude.gov.br/bvs/publicacoes/documento_

referencia_programa_nacional_seguranca.pdf

World Health Organization (WHO). Medication without harm.

Geneva: World Health Organization; 2017 [cited 2024 Jan 15].

Avialable from: https://www.who.int/initiatives/medicationwithout-

harm

World Health Organization (WHO). Patient safety research

course. Geneva: World Health Organization; 2012 [cited 2024

Jan 15]. Avialable from: http://www.who.int/patientsafety/

research/online_course/en/

Institute of Medicine (US) Committee on Quality of Health Care in

America. To Err is Human: Building a Safer Health System. Kohn LT,

Corrigan JM, Donaldson MS, editors. Washington (DC): National

Academies Press (US); 2000.

Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria MS/GM

nº 529, de 1 de abril de 2013. Brasília, DF: Diário Oficial da União;

[citado 2024 Jan 15]. Disponível em: http://bvsms.saude.gov.

br/bvs/saudelegis/gm/2013/prt0529_01_04_2013.html

Bigham BL, Bull E, Morrison M, Burgess R, Maher J, Brooks SC,

et al. Patient safety in emergency medical services: executive

summary and recommendations from the Niagara Summit. CJEM.

;13(1):13-8.

Abebe E, Chui MA. Exploring barriers to medication safety in

an Ethiopian hospital emergency department: a human factors

engineering approach. INNOVATIONS in pharmacy. 2018;9(1):1-

Shitu Z, Aung MM, Kamauzaman TH, Rahman AF. Prevalence and

characteristics of medication errors at an emergency department

of a teaching hospital in Malaysia. BMC Health Services Research.

;20(1):1-7.

Izadpanah F, Nikfar S, Bakhshi Imcheh F, Amini M, Zargaran M.

Assessment of frequency and causes of medication errors in

pediatrics and emergency wards of teaching hospitals affiliated

to Tehran university of medical sciences (24 hospitals). J Med Life.

;11(4):299-305.

Mendes JR, Lopes MC, Campanharo CR, Okuno MF, Batista

RE. Types and frequency of errors in the preparation and

administration of drugs. Einstein (São Paulo). 2018;16(3):1-6.

Bourdon LM, Alvarez AO, Llamas JG, Cañada MK, Garbayo JL,

Olvera SG. A study of medication errors during the prescription

stage in the pediatric critical care services of a secondary-tertiary

level public hospital. BMC Pediatr. 2020;20(1):549.

Westbrook JI, Raban MZ, Walter SR, Douglas H. Task errors

by emergency physicians are associated with interruptions,

multitasking, fatigue and working memory capacity: a prospective,

direct observation study. BMJ Quality & Safety. 2018;27(8):655-

Maroto MM, Carpintero LS. Errores en la administración de

medicación en un servicio de urgencias: conocer para disminuir el

riesgo. Rev Esp Salud Publica. 2018;92:e201806038.

Oliveira BH, de Sousa VM, Fernandes KJ, Urtiga VL, Carvalho LJ,

Carvalho RE, et al. Errors in medication dosage in the urgency unit

of a hospital. J Nurs UFPE On Line. 2019;13:e239792.

Otaibi HA, Moawed SA, Harbi MF. Nurses’ Medication Errors in

the Pediatric Emergency Departments in Saudi Arabia. Middle

East Journal of Nursing. 2018;12(1):3-13.

Hirata KM, Kang AH, Ramirez GV, Kimata C, Yamamoto LG.

Pediatric Weight Errors and Resultant Medication Dosing

Errors in the Emergency Department. Pediatr Emerg Care.

;35(9):637-42.

George J. Exploring the common prescribing errors that occur in

the emergency department. Emerg Nurse. 2020;28(2):17-22.

Sender IT, García MM, Errasquin BM, Llorente BM, Hervás NE,

Silveira ED. Gravedad de los errores de conciliación producidos

en el servicio de urgencias en pacientes ancianos. Emergencias.

;32(3):188-90.

Cabilan CJ, Hughes JA, Shannon C. The use of a contextual,

modal and psychological classification of medication errors in the

emergency department: a retrospective descriptive study. J Clin

Nurs. 2017;26(23-24):4335-43.

Acheampong F, Tetteh AR, Anto BP. Medication administration

errors in an adult emergency department of a tertiary health care

facility in Ghana. J Patient Saf. 2016;12(4):223-8.

Murray KA, Belanger A, Devine LT, Lane A, Condren ME. Emergency

department discharge prescription errors in an academic medical

center. Proc (Bayl Univ Med Cent). 2017;30(2):143-6.

Barstow L, Herman E, Phillips H, Maloney P. Assessment of

emergency department antibiotic discharge prescription dosing

errors for pediatric patients in a community hospital health

system. Pediatr Emerg Care. 2020;36(7):e393-96.

Dorothy A, Yadesa TM, Atukunda E. Prevalence of medication

errors and the associated factors: a prospective observational

study among cancer patients at Mbarara Regional Referral

Hospital. Cancer Manag Res. 2021;13:3739-48.

Parthasarathi A, Puvvada R, Patel H, Bhandari P, Nagpal S.

Evaluation of medication errors in a tertiary care hospital of a lowto

middle-income country. Cureus. 2021;13(7):e16769.

Isaacs AN, Ch’ng K, Delhiwale N, Taylor K, Kent B, Raymond A.

Hospital medication errors: a cross-sectional study. Int J Qual

Health Care. 2021;33(1):mzaa136.

Lahti CL, Takala A, Holmström AR, Airaksinen M. What severe

medication errors reported to health care supervisory authority

tell about medication safety? J Patient Saf. 2021;17(8):e1179-85.

McMahon M, Hatton C, Bowring DL, Hardy C, Preston NJ. The

prevalence of potential drug-drug interactions in adults with

intellectual disability. J Intellect Disabil Res. 2021;65(10):930-40.

Moudgil K, Premnath B, Shaji JR, Sachin I, Piyari S. A prospective

study on medication errors in an intensive care unit. Turk J Pharm

Sci. 2021;18(2):228-32.

Tyynismaa L, Honkala A, Airaksinen M, Shermock K, Lehtonen

L. Identifying high-alert medications in a university hospital by

applying data from the medication error reporting system. J

Patient Saf. 2021;17(6):417-24.

Gebre M, Addisu N, Getahun A, Workye J, Gamachu B, Fekadu G,

et al. Medication errors among hospitalized adults in medical wards

of Nekemte Specialized Hospital, West Ethiopia: a prospective

observational study. Drug Healthc Patient Saf. 2021;13:221-28.

Nguyen TL, Blache GL, Kinowski JM, Marson CR, Rougier M,

Spence J, et al. Improving medication safety: Development and

impact of a multivariate model-based strategy to target high-risk

patients. Plos One. 2017;12(2):e0171995.

Azar C, Thomas L, Champel VG, Laroche ML, Grau M, Allué

D, et al. Patterns of medication errors involving older adults

reported to the French medication error guichet. J Patient Saf.

;18(2):e514-e521.

Cornejo EV, Ríos OM, Villegas LE, Ortega EJ, Estupiñán FV,

Espinosa JG. Medication errors in a cohort of pediatric patients

with acute lymphoblastic leukemia on remission induction

therapy in a tertiary care hospital in Mexico. Cancer Med.

;8(13):5979-87.

Baraki Z, Abay M, Tsegay L, Gerensea H, Kebede A, Teklay H.

Medication administration error and contributing factors among

pediatric inpatient in public hospitals of Tigray, northern Ethiopia.

BMC Pediatr. 2018;18:321.

Feyissa D, Kebede B, Zewudie A, Mamo Y. Medication error and

its contributing factors among pediatric patients diagnosed with

infectious diseases admitted to Jimma University Medical Center,

Southwest Ethiopia: prospective observational study. Integr

Pharm Res Pract. 2020;9:147-53.

Azar C, Allué D, Rabier MB, Chouchana L, Rocher F, Durand D, et

al. Patterns of medication errors involving pediatric population

reported to the French Medication Error Guichet. Pharm Pract

(Granada). 2021;19(2):2360.

Roumeliotis N, Pullenayegum E, Rochon P, Taddio A, Parshuram C.

A modified Delphi to define drug dosing errors in pediatric critical

care. BMC Pediatr. 2020;20:488.

Alyahya MS, Hijazi HH, Alolayyan MN, Ajayneh FJ, Khader YS,

Al-Sheyab NA. The association between cognitive medical errors

and their contributing organizational and individual factors. Risk

Manag Healthc Policy. 2021;14:415-30.

Wondmieneh A, Alemu W, Tadele N, Demis A. Medication

administration errors and contributing factors among nurses: a

cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia.

BMC Nurs. 2020;19:4.

Alemu W, Belachew T, Yimamc I. Medication administration errors

and contributing factors: A cross sectional study in two public

hospitals in Southern Ethiopia. International Journal of Africa

Nursing Sciences. 2017;7:68-74.

Johnson M, Sanchez P, Langdon R, Manias E, Levett-Jones T,

Weidemann G, et al. The impact of interruptions on medication

errors in hospitals: an observational study of nurses. J Nurs

Manag. 2017;25(7):498-507.

Topcu I, Türkmen AS, Sahiner NC, Savaser S, Sen H. Physicians’ and

nurses’ medical errors associated with communication failures. J

Pak Med Assoc. 2017;67(4):600-4.

Sharma R, Prakash A, Chauhan R, Dhibar DP. Overcrowding an

encumbrance for an emergency health-care system: A perspective

of Health-care providers from tertiary care center in Northern

India. J Educ Health Promot. 2021;10:5.

Gontijo MD, Viegas SM, Freitas AT, Maia AF, Silveira EA, Quites

HF. Professional safety constructs in the context of Primary

Health Care. Rev Bras Enferm. 2020;73(6):e20190529.

Di Simone E, Fabbian F, Giannetta N, Dionisi S, Renzi E,

Cappadona R, et al. Risk of medication errors and nurses’ quality

of sleep: a national cross-sectional web survey study. Eur Rev Med

Pharmacol Sci. 2020;24(12):7058-62.

Yakubu RC, Nguah SB, Bisah NA. Comparison of paediatric weight

estimation methods at a tertiary hospital in Ghana. Afr J Emerg

Med. 2021;11(2):252-7.

Lahti CL, Takala A, Holmström AR, Airaksinen M. What severe

medication errors reported to health care supervisory authority

tell about medication safety? J Patient Saf. 2021;17(8):e1179-85.

Schneider J, Algharably EA, Budnick A, Wenzel A, Dräger D, Kreutz

R. High prevalence of multimorbidity and polypharmacy in elderly

patients with chronic pain receiving home care are associated

with multiple medication-related problems. Front Pharmacol.

;12:686990.

Amaya JM, García FG, Castro SG, Cárdenas MS, Alarcón MA,

Delgado DÁG. Medication errors: electronic vs. paper-based

prescribing. Experience at a tertiary care university hospital. J Eval

Clin Pract. 2016;22(5):751-4.

Pérez RI, Balint FP, Cruz EL, Gómez SE, Pastrana LI.

Intravenous administration errors intercepted by smart

infusion technology in an adult intensive care unit. J Patient

Saf. 2021;17(6):430-6.

Downloads

Publicado

2024-01-26

Como Citar

de Camargo Bendinelli, P., & Lopes Tomaz , S. . (2024). Tipos e causas de erros de uso de medicamentos em serviços hospitalares de emergência:: uma revisão integrativa. JBMEDE - Jornal Brasileiro De Medicina De Emergência, 3(4). https://doi.org/10.54143/jbmede.v3i4.67