Prescription errors in Brazilian hospitals: A multi-centre exploratory survey

Cadernos de Saude Publica

Volumn 25, Issue 2, 2009, Pages 313-320

  Miasso, Adriana Inocenti ^a   De Oliveira, Regina Célia ^b   De Camargo Silva, Ana Elisa Bauer ^c   De Lyra Jr , Divaldo Pereira ^d   Gimenes, Fernanda Raphael Escobar ^e   Fakih, Flávio Trevisan ^f   De Bortoli Cassiani, Sílvia Helena ^a  

^a UNIVERSITY OF SÃO PAULO   (Brazil)

^b FEDERAL UNIVERSITY OF PERNAMBUCO   (Brazil)

^c FEDERAL UNIVERSITY OF GOIÁS   (Brazil)

^d FEDERAL UNIVERSITY OF SERGIPE   (Brazil)

^e UNIVERSIDADE CAMILO CASTELO BRANCO   (Brazil)

^f FEDERAL UNIVERSITY OF SÃO PAULO   (Brazil)

Author keywords

Drug prescriptions; Medication errors; Medication systems

Indexed keywords

EID: 63349108201     PISSN: 0102311X     EISSN: 16784464     Source Type: Journal    
DOI: 10.1590/s0102-311x2009000200009     Document Type: Article

References (41)

1. Carvalho VT, Cassiani SHB, Chiericato C, Miasso AI. Erros mais comuns e fatores de risco na administração de medicamentos em unidades básicas de saúde. Rev Latinoam Enferm 1999; 7:67-75.
2. Rosa MB, Perini E. Erros de medicação: quem foi? Rev Assoc Med Bras 2003; 49:335-41.
3. National Coordinating Council for Medication Error Reporting and Prevention. What is medication error? http://www.nccmerp.org/council/coun cil1996-09-04.html (accessed on 14/Sep/2005).
4. Bond CA, Raehl CL, Franke T. Medication errors in United States hospitals. Pharmacotherapy 2001; 21:1023-36.
5. Kohn LT, Corrigan JM, Donaldson MS, editors. Institute of Medicine report. To err is human: building a safer health system. Washington DC: National Academies Press; 1999.
6. Timbs O. Leading role for pharmacists to reduce drug errors and improve patient safety. Pharm J 2002; 268:39.
7. Otero-López MJ. Nuevas iniciativas para mejorar la seguridad de la utilización de los medicamentos en los hospitales. Rev Esp Salud Pública 2004; 78:323-39.
8. Roughead EE. The nature and extent of drug-related hospitalisations in Australia, 1999. J Qual Clin Pract 1999; 19:19-22.
9. Paredes NM, Parras MEO. Errores de medicación en los profesionales sanitarios y sus consecuencias médico legales. Rev Méd Legal 2006; 13:24-9.
10. Giachetto G, Banchero P, Telechea H, Speranza N, Wolaj M, Toledo M, et al. Uso racional de medicamentos: ¿qué conocen los médicos residentes sobre los fármacos de uso corriente? Rev Med Urug 2003; 19:231-6.
11. Kawano DF, Pereira LRL, Ueta JM, Freitas O. Acidentes com os medicamentos: como minimizálos? Rev Bras Ciênc Farm 2006; 42:487-95.
12. Miasso AI, Grou CR, Cassiani SHB, Silva AEBC, Fakih FT. Erros de medicação: tipos, fatores causais e providências tomadas em quatro hospitais brasileiros. Rev Esc Enferm USP 2006; 40:524-32.
13. Monzani AAS. A ponta do iceberg: o método de notificaç ão de erros de medicação em um hospital geral privado no município de Campinas-SP [Dissertação de Mestrado]. Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo; 2006.
14. Anacleto TA, Perini E, Rosa MB, César CC. Drugdispensing errors in the hospital pharmacy. Clinics 2007; 62:243-50.
15. Miasso AI, Suva AEBC, Cassiani SHB, Grou CR, Oliveira RC, Fakih FT. O processo de preparo e administração de medicamentos: identificação de problemas para propor melhorias e prevenir erros de medicação. Rev Latinoam Enferm 2006; 14:354-63.
16. Bobb A, Gleason K, Husch M, Feinglass J, Yamold PR, Noskin GA. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med 2004; 164:785-92.
17. Ministério da Saúde. Lei no. 5.991. Dispõe sobre o controle sanitário do comércio de drogas, medicamentos, insumos farmacêuticos e correlatos, e dá outras providências. Diário Oficial da União 1973; 17 jan.
18. Lyra Junior DP, Prado MCTA, Abriata JP, Pelá IR. Prescription orders as cause of risk of drug-related problems. Seguim Farmacoter 2004; 2:86-96.
19. Gimenes FRE, Miasso AI, Lyra Junior DP, Grou CR. Electronic prescription as contributory factor for hospitalized patients' safety. Pharmacy Practice 2006; 4:13-7.
20. Shulman R, Singer M, Goldstone J, Belllngan G. Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Crit Care 2005; 9: R516-21.
21. Lisby M, Nielsen LP, Mainz J. Errors in the medication process: frequency, type, and potential. Int J Qual Health Care 2005; 17:15-22.
22. Organização Mundial da Saúde. Guia do instrutor em práticas da boa prescrição médica. Genebra: Organização Pan-Americana da Saúde; 2001.
23. National Coordinating Council for Medication Error Reporting and Prevention. Recommendations to enhance accuracy of prescription writing, 2005. http://www.nccmerp.org (accessed on 12/ Nov/2007).
24. Fontán JE, Maneglier V, Nguyen VX, Loirat C, Brion F. Medication errors in hospitals: computerized unit dose drug dispensing system versus ward stock distribution system. Pharm World Sci 2003; 25:112-7.
25. Kalmeljer MD, Holtzer W, van Dongen R, Guchelaar HJ. Implementation of a computerized physician medication order entry system at the Academic Medical Centre in Amsterdam. Pharm World Sci 2003; 25:88-93.
26. KoppelR, Metlay JP. Cohen A, Abaluck B, Localio AR, Kimmel SE, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; 293:1197-203.
27. Lesar TS. Medication prescribing error reporting and prevention program: a 14-year experience. Medscape Pharmacists 2000; 1:1-28.
28. Cohen MR. Preventing medications errors related to prescribing. In: Cohen MR, editor. Medication errors causes, prevention, and risk management. Washington DC: American Pharmaceutical Association; 2000. p. 88.1-8.23.
29. Louro E, Romano-Lieber NS, Ribeiro E. Eventos adversos a antibióticos em pacientes internados em um hospital universitário. Rev Saúde Pública 2007; 41:1042-8.
30. Vaida AJ, Peterson J. Incomplete directions can lead to dispensing errors. Pharmacy Times 2002; 5:34-8.
31. Scarsi KK, Fotis MA, Noskin GA. Pharmacist participation in medical rounds reduces medication errors. Am J Health Syst Pharm 2002; 59:2089-92.
32. Davis NM. Medical abbreviations: 15,000 conveniences at the expense of communications and safety. Huntington Valley: Neil M. Davis Associates; 2001.
33. Benjamin DM. Reducing medication errors and increasing patient safety: case studies in clinical pharmacology. J Clin Pharmacol 2003; 43:768-83.
34. Cassiani SHB, Freire CC, Gimenes FRE. A prescrição médica eletrônica em um hospital universitário: falhas de redação e opiniões de usuários. Rev Esc Enferm USP 2003; 37:51-60.
35. Agência Nacional de Vigilância Sanitária. Consulta pública no. 50. Dispõe sobre o Vocabulário Controlado de Formas Farmacêuticas. Diário Oficial da União 2007; 30 mai.
36. Joint Commission on Accreditation of Healthcare Organizations. National patient safety goals for 2006. http://www.jointcommission.org/General Public/NPSG/06-gp-npsg.htm (accessed on 22/ May/2006).
37. Institute for Safe Medication Practices. Special issue: do not use these dangerous abbreviations or dose designations, 2005. http://www.ismp.org/ Newsletters/acutecare/articles/20030220-2.asp (accessed on 12/Nov/2007).
38. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP National Survey of Pharmacy Practice in Hospital Settings: prescribing and transcribing - 2004. Am J Health-Syst Pharm 2005; 62:378-90.
39. Conselho Federal de Medicina. Código de ética médica, 1998. http://www.portalmedico.org.br/ index.asp?opcao= codigoetica&portal (acessed on 12/Jan/2007).
40. Bates DW, Teich J, Lee J, Seger D, Kuperman G, Maluf N, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999; 6:313-21.
41. Kaushal R, Barker KN, Bates DW How can information technology improve patient safety and reduce medication errors in children's health care? Arch Pediatric Adolesc Med 2001; 55:1002-6.