Patient safety and medication errors: a literature review

Resumo

Only in the last decades has patient safety and human errors been discussed, this is due to the publication of the book: To err is human: building a safer health care system, published In 1999 by the Institute of Medicine of the United States. Many errors occur because the practitioner does not have knowledge about the subject, so health care institutions should promote ways to keep their staff current while maintaining patient safety. It was aimed at the present study analyze through a systematized review in the literature the subject of patient safety and medication errors. The present work deals with a bibliographic research with an exploratory and descriptive character. With regard to patient safety, 12 scenarios were found regarding medication errors: Prescription error; Dispensing error; Error of omission; Time error; Error of unauthorized medication; Dose error; Presentation error; Preparation error; Administration error; Error for use of impaired medications; Monitoring error; Error by not adhering to the patient and his family. And the inducing factors to the error: Failures in the health care system; Lack of notification culture; Lack of analysis of events; Lack of adequate material resources; Professional overload; Lack of operational protocols and routines implemented; Rapid deployment of processes; Non adherence by the patient to the proposed treatments. There are still some factors that are considered as protectors to the error, that is, they make difficult the event of the error, they are: Continued education; Certainty of procedures; Technical knowledge and ability. It was observed that health institutions and managers should conduct an investigation into how much error-inducing factors are interfering with the performance of their staff's activities and carrying out the necessary interventions, since the human factor is often considered the main reason for Error, but the error does not occur in isolation, so it is not enough to punish the professional and not perform a detailed analysis of the facts that favored the error.