einstein (São Paulo). 10/Sep/2018;16(3):eAO4146.

Types and frequency of errors in the preparation and administration of drugs

Josiane Ribeiro Mendes ORCID logo , Maria Carolina Barbosa Teixeira Lopes ORCID logo , Cássia Regina Vancini-Campanharo ORCID logo , Meiry Fernanda Pinto Okuno ORCID logo , Ruth Ester Assayag Batista ORCID logo

DOI: 10.1590/S1679-45082018AO4146

ABSTRACT

Objective:

To identify compatibility, types and frequency of errors in preparation and administration of intravenous drugs.

Methods:

A cross-sectional and descriptive study performed at the emergency department of a university hospital in the city of São Paulo (SP). The sample consisted of 303 observations of the preparation and administration of intravenous drugs by nursing aides, nursing technicians and registered nurses, using a systematized script, similar to a checklist. The following variables were collected: errors related to dispensing, omission, schedule, unauthorized administration, dosage, formulation, incompatibility, preparation and administration.

Results:

In the preparation stage, the following errors were identified: no hand hygiene (70.29%), and no use of aseptic technique (80.85%). Upon administration, no hand hygiene (81.18%), and no use of aseptic technique (84.81%). In 31.35% of observations, there was more than one medication at the same time for the same patient, of which 17.89% were compatible, 56.84% were incompatible and 25.26% were not tested, according to the Micromedex database.

Conclusion:

In both preparation and administration stages, the most frequent errors were no hand hygiene and no use of aseptic technique, indicating the need to develop and implement education programs focused on patient safety.

Types and frequency of errors in the preparation and administration of drugs

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