title: Using Positive Deviance to reduce medication errors in a tertiary care hospital.
abstract: The number of medication errors occurring in healthcare is large and many are preventable. To analyze medication errors and evaluate whether Positive Deviance is effective in reducing them.
  
  
  
  The study was divided into three phases: (2011- Phase I, control period; 2012 - Phase II, manager intervention, and 2013 - Phase III, frontline healthcare worker intervention). In Phases II and III, the Positive Deviance method (PD) was used to mitigate medication errors classified as "C" and higher according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). The errors reported were compared across the three study phases, as well as by the location of the hospital unit, shift, cause, consequence, and the professional associated with the error.
  
  
  
  A total of 4013 reported medication errors were analyzed. The largest number of errors occurred at the time the medications were administered, accounting for 35.5 % of errors in Phase I; 43.1 % in Phase II, and 55.6 % in Phase III. Nursing staff was most commonly associated with errors; 46.4 % of errors in Phase I, 48.5 % in Phase II, and 58.7 % in Phase III. With each intervention, a decrease was observed in the reported error rate of 0.12 (CI 95 %, 0.18 to 0.07).
  
  
  
  Positive Deviance proved to be effective, primarily when healthcare professionals who were involved in errors participated, as was observed in Phase III of this study.
authors: Pharmacy, Hospital Israelita Albert Einstein, São Paulo, Brazil.
authors: Fabio Teixeira
authors: FT
authors: Ferracini
authors: Division of Medical Practice, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627 - bloco A1, 1° andar, sala 108, Morumbi, São Paulo, Brazil, 05651-901. alexandre.marra@einstein.br.|Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA. alexandre.marra@einstein.br.
authors: Alexandre R
authors: AR
authors: Marra
authors: Division of Medical Practice, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627 - bloco A1, 1° andar, sala 108, Morumbi, São Paulo, Brazil, 05651-901.
authors: Claudio
authors: C
authors: Schvartsman
authors: Division of Medical Practice, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627 - bloco A1, 1° andar, sala 108, Morumbi, São Paulo, Brazil, 05651-901.
authors: Oscar F Pavão
authors: OF
authors: Dos Santos
authors: Statistics Department, Instituto Israelita de Ensino e Pesquisa (IIEP), Hospital Israelita Albert Einstein, São Paulo, Brazil.
authors: Elivane da Silva
authors: Eda S
authors: Victor
authors: Board of Healthcare Practice, Quality, Safety, and Environment, Hospital Israelita Albert Einstein, São Paulo, Brazil.
authors: Neila Maria Marques
authors: NM
authors: Negrini
authors: Pharmacy, Hospital Israelita Albert Einstein, São Paulo, Brazil.
authors: Wladimir Mendes Borges
authors: WM
authors: Filho
authors: Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
authors: Michael B
authors: MB
authors: Edmond
mesh_terms: D016907:Adverse Drug Reaction Reporting Systems / Q000592:standards* / Q000639:trends; D006282:Health Personnel / Q000592:standards* / Q000639:trends; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control* / Q000639:trends; D024382:Professional Role; D011446:Prospective Studies; D062606:Tertiary Care Centers / Q000592:standards* / Q000639:trends
keywords: Medication errors; Patient safety; Prevention