Moving towards Healthcare Quality and Patient Safety Improvement by Diagnosing the Medication System at a Brazilian University Hospital

2.50
Hdl Handle:
http://hdl.handle.net/10755/147719
Type:
Presentation
Title:
Moving towards Healthcare Quality and Patient Safety Improvement by Diagnosing the Medication System at a Brazilian University Hospital
Abstract:
Moving towards Healthcare Quality and Patient Safety Improvement by Diagnosing the Medication System at a Brazilian University Hospital
Conference Sponsor:Sigma Theta Tau International
Conference Year:2007
Author:Miasso, Adriana Inocenti, PhD
P.I. Institution Name:University of S?o Paulo, Ribeir?o Preto College of Nursing. WHO Collaborating Centre for Nursing Research Development
Title:Doctor of Nursing. Professor
Co-Authors:Ana Elisa Bauer de Camargo Silva, ; Fernanda R.E. Gimenes, ; Silvia H. De Bortoli Cassiani, DNS, RN
[Scientific session research presentation] It is crucial for health care providers involved with medication to be familiar with its system. This descriptive study was carried out in a Central-West Brazilian teaching hospital, where the medication process was analyzed and improvement measures were proposed. Data were collected through disguised-observation; interviews made with the institution health care professionals and review of physician orders. The medication system in the hospital is characterized by prescriptions hand-writing daily in two copies; 24 hour open pharmacy and by individualized doses distribution system. Moreover, medications are prepared and administered by different nurses, there was neither a medication information center nor a formal error investigation committee. The environment was the main problem observed during prescribing (75%) and distributing (30.6%) drugs, as these occur in an inappropriate space with noise and frequent interruptions. Problems during medication preparation were also detected (45.9%) which were related to nursing procedures and anticipated preparation. 40 professionals were interviewed and they pointed the most frequent errors: physician orders (29%) and wrong time (20.6%) due to individual errors, lack of attention (47.4%) and work overload (14.5%). After that, 294 prescription orders were analyzed retrospectively, and from those 34.7% was unreadable or partially readable; 37.8% did not contain the physician?s full and readable name; bland names were found in 37.4%, and bland as well as generic names in 62.2% of them; 94.9% of prescription orders were incomplete for one or more items and 29.9% contained erasures. Suggestions made were due to creation of a multidisciplinary patient safety commission; establishment of a medication error reporting program; adopt a non-punitive culture; improve work environments; create a continuing education program; implement the computerized physician order entry, unit dose and bar code. Analyzing the medication system and its process allowed us to identify areas in which safer medication administration can occur.
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Sigma Theta Tau International

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleMoving towards Healthcare Quality and Patient Safety Improvement by Diagnosing the Medication System at a Brazilian University Hospitalen_GB
dc.identifier.urihttp://hdl.handle.net/10755/147719-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Moving towards Healthcare Quality and Patient Safety Improvement by Diagnosing the Medication System at a Brazilian University Hospital</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Sigma Theta Tau International</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2007</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Miasso, Adriana Inocenti, PhD</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">University of S?o Paulo, Ribeir?o Preto College of Nursing. WHO Collaborating Centre for Nursing Research Development</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Doctor of Nursing. Professor</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">amiasso@eerp.usp.br</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Ana Elisa Bauer de Camargo Silva, ; Fernanda R.E. Gimenes, ; Silvia H. De Bortoli Cassiani, DNS, RN</td></tr><tr><td colspan="2" class="item-abstract">[Scientific session research presentation] It is crucial for health care providers involved with medication to be familiar with its system. This descriptive study was carried out in a Central-West Brazilian teaching hospital, where the medication process was analyzed and improvement measures were proposed. Data were collected through disguised-observation; interviews made with the institution health care professionals and review of physician orders. The medication system in the hospital is characterized by prescriptions hand-writing daily in two copies; 24 hour open pharmacy and by individualized doses distribution system. Moreover, medications are prepared and administered by different nurses, there was neither a medication information center nor a formal error investigation committee. The environment was the main problem observed during prescribing (75%) and distributing (30.6%) drugs, as these occur in an inappropriate space with noise and frequent interruptions. Problems during medication preparation were also detected (45.9%) which were related to nursing procedures and anticipated preparation. 40 professionals were interviewed and they pointed the most frequent errors: physician orders (29%) and wrong time (20.6%) due to individual errors, lack of attention (47.4%) and work overload (14.5%). After that, 294 prescription orders were analyzed retrospectively, and from those 34.7% was unreadable or partially readable; 37.8% did not contain the physician?s full and readable name; bland names were found in 37.4%, and bland as well as generic names in 62.2% of them; 94.9% of prescription orders were incomplete for one or more items and 29.9% contained erasures. Suggestions made were due to creation of a multidisciplinary patient safety commission; establishment of a medication error reporting program; adopt a non-punitive culture; improve work environments; create a continuing education program; implement the computerized physician order entry, unit dose and bar code. Analyzing the medication system and its process allowed us to identify areas in which safer medication administration can occur.</td></tr></table>en_GB
dc.date.available2011-10-26T09:35:33Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T09:35:33Z-
dc.description.sponsorshipSigma Theta Tau Internationalen_GB
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