title: [The medication preparation and administration process: problem identification in order to propose improvements and prevent medication errors].
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.
authors.affiliation: Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. amiasso@eerp.usp.br
authors.forename: Adriana Inocenti
authors.initials: AI
authors.lastname: Miasso
authors.forename: Ana Elisa Bauer de Camargo
authors.initials: AE
authors.lastname: Silva
authors.forename: Silvia Helena de Bortoli
authors.initials: SH
authors.lastname: Cassiani
authors.forename: Cris Renata
authors.initials: CR
authors.lastname: Grou
authors.forename: Regina Célia
authors.initials: RC
authors.lastname: de Oliveira
authors.forename: Flávio Trevisan
authors.initials: FT
authors.lastname: Fakih
mesh_terms: D004339:Drug Compounding / Q000592:standards*; D004348:Drug Labeling / Q000592:standards*; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control*; D008510:Medication Systems, Hospital / Q000458:organization & administration*; D009729:Nursing / Q000592:standards*