ANALYSIS OF ENVIRONMENTAL AND ORGANIZATIONAL ASPECTS AND STRATEGIES FOR PREVENTING RISKS OF MEDICATION ERRORS IN A TEACHING HOSPITAL

Ariadne Spadoti MS., Silvana Andréa Molina Lima PhD., *César Tadeu Spadella MD, PhD.

ABSTRACT

The present study was conducted to identify the causes of medication errors (ME) in a public teaching hospital and seeking strategies to reduce them. A prospective, cross-sectional, descriptive, exploratory, and observational study of the physical and organizational structure of 7 different units of the hospital and the level of organization of the processes involved in the medication cycle (from prescription to administration) was performed. The study examined the medication process of 155 patients, including 465 medical prescriptions and 7,080 prescription drugs. Risk factors for ME were more associated with deficiencies of the health system than with individual failures. Deficiency of facilities, inadequate use of space, disorganized drug storage cabinets, poor lighting, excessive noise and failure and/or unavailability of equipment were observed in most of the units. Quantity, distribution and insufficient training of nursing professionals, as well as work overload, double routine activities and frequent interruptions of tasks, were also observed. Errors in the medication process were observed at all stages of the cycle, ranging from failures of communication between team members to operational deviations that endangered patient safety. Efforts by directors and health professionals should be concentrated on creating a work environment that values comfort and adequacy of facilities, hiring an adequate number of employees with high quality and sufficient training, improving the availability and correct operation of the equipment, and adopting operating protocols that guide healthcare professionals at all stages of the medication cycle.

Keywords: Healthcare, Medication administration, Medication errors, Nursing errors, Patient safety.