[The medication preparation and administration process: problem identification in order to propose improvements and prevent medication errors].
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.
Miasso
Adriana Inocenti
AI
Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. amiasso@eerp.usp.br
Silva
Ana Elisa Bauer de Camargo
AE
Cassiani
Silvia Helena de Bortoli
SH
Grou
Cris Renata
CR
de Oliveira
Regina Célia
RC
Fakih
Flávio Trevisan
FT
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*