Erros na administração de medicamentos em unidades de urgência e emergência

Abstract

Descriptive study in order to characterize errors in medication administration in urgent and emergency units. The study covers the doses of drugs administered intravenously, intramuscularly, subcutaneously and sublingually to patients seen in the infirmary, injectable, room, hydration and emergency rooms.Data collection took place in two units of the fixed pre-hospital network in the State of Goiás, in a period of twenty days in each unit, with ten consecutive days during the day and ten days at night, totaling 480 hours. Direct non-participant observation of professionals was performed during the administration of medications by research assistants and recorded in a checklist. The data were inserted by double check in a Microsoft Excel spreadsheet and analyzed using descriptive statistics. The chi-square test or fisher's exact test was performed to compare the proportions of errors during the day and night. The project was approved by the Ethics Committee of the Pontifical Catholic University of Goiás with opinion N° 2.496.493 and by the Ethics Committee of the co-participating institution, opinion N° 2.631.336 and attended to all ethical aspects of research in human beings. 824 administered doses were observed and 4,544 errors were identified during drug administration, with an average of 5.5 errors per dose. The errors occurred mainly in the night shift. The most frequent ones were not checking the patient's identity, not informing the patient about the medication administered and checking incorrectly. These errors were also present in the administration of 124 doses of potentially dangerous drugs, in addition to not checking for allergy before administering the drug. During administration, professionals were interrupted by telephone, conversation and patient agitation. The environment had inadequate air circulation, intense flow of people and noises or noises. It was concluded that there was a 100% error rate in medication administration. The errors observed and related to human, systemic or environmental failures are preventable and can trigger adverse events in patients. Preventive measures must be adopted to ensure patient safety at this important stage of health care, in urgent and emergency units