Tipos e causas de erros de uso de medicamentos em serviços hospitalares de emergência:
uma revisão integrativa
DOI:
https://doi.org/10.54143/jbmede.v3i4.67Palavras-chave:
Serviço hospitalar de emergência;, Segurança do paciente;, Gestão em saúdeResumo
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
Como Citar
Edição
Seção
Categorias
Licença
Copyright (c) 2023 JBMEDE - Jornal Brasileiro de Medicina de Emergência
Este trabalho está licenciado sob uma licença Creative Commons Attribution 4.0 International License.
