SUMMARY
Introduction
Providing safe, effective, timely and individualized care is a major challenge in health care. Currently, the main errors in health care are related to medication errors. These errors can cause damage, especially in pediatrics, due to the immaturity of the organs and the variation in weight and body surface. In this way, the importance of nursing in this scenario for the guarantee of safe care is perceived.
Objective
Investigate the practice of nursing professionals on the medication administration process, as well as the circumstances that lead to errors.
Method
Descriptive, quantitative study conducted with 147 nursing professionals in neonatal and pediatric intensive care units. For data collection, a questionnaire elaborated and based on the recommendations of the Guideline for Prevention of Intravascular catheter-related infections related to the practice of medication administration was used and then descriptive analysis of the data was performed.
Results
The professionals pointed out weaknesses of the practice such as double checking of medications, administration of medications prepared by the partner, delays and lack of verification of prescriptions. The most common errors resulted from erroneous dosages and environmental factors were presented as critical points.
Conclusion
The findings interfere with the consolidation of safety practices in medication administration in pediatrics and neonatology, suggesting the need for equipment qualification and continuous monitoring of the work process.
Palavras-key: Medication errors; Security; Nursing
INTRODUCTION
Currently, one of the biggest challenges of health services is to provide safe, effective, timely and individualized care since, due to technological and scientific advances and the inclusion of increasingly complex techniques, the risks to patient safety have been enhanced. 1
The report To Err is Human Building a Safer Health System Institute of Medicine of the United States of America (USA), published in 2000, exposed epidemiological studies in which it was estimated that between 44,000 and 98,000 deaths were recorded in the country per year due to errors in medical care, cases of which 30% were related to medication errors. 2 In Brazil, the National System of Toxic-Pharmacological Information (Sintox) reveals that drugs are in first place among agents that cause poisoning in humans, and second among those that cause poisoning in general. 1 Also in Brazil, a major study conducted in a hospital in Rio de Janeiro demonstrated a 14.3% incidence of adverse events caused by drugs, 31.2% of which caused a serious health risk requiring life support. 3
A medication error is defined as an avoidable adverse event, temporary or permanent, that occurs at any stage of drug therapy and may or may not cause harm to the patient. The damage is determined to be an adverse event, which is considered an incident that results in harm to the patient’s health and affects recovery, extends the time and costs of hospitalization and leads to death. Medication errors can be classified as follows: error of prescription, distribution, by omission, by schedule, by the use of unauthorized drugs, of dose, presentation, preparation, administration, control or by the non-adherence of the patient or the family. 4
Estimates show that, among all hospitalized patients, approximately 3% develop an adverse event due to medication use. Although the frequency is similar between children and adults, the potential risk of harm is three times higher in paediatric and neonatal patients. 4.5 The increased risk in children is attributed to organ immaturity and their influence on drug metabolism, as well as variation in weight and body surface area. In association with this fact, we can add that many drugs used in pediatrics were designed for adults; Then, as a result of fractionation of doses, they can lead to errors in the preparation and administration process. 6.7
Several studies have confirmed that errors during drug administration can be avoided, which shows the important participation of the nursing team in the system to promote patient safety. 6 This fact is even more striking in terms of pediatric care, since a systematic review of medication errors in children has shown that the medication administration process exhibited a higher frequency of errors, among other findings, with a rate of 72% to 75% and, consequently, it is imperative that all institutions and health teams promote changes in organizational culture that allow analysis with a restructuring of processes and the creation of security strategies in order to reduce, to an acceptable minimum, the unnecessary risks and harms associated with care 8. In pediatric and neonatal intensive care units, the number of errors is 22 to 59 errors per thousand doses and approximately 2.5% of these children suffer drug-related adverse events. 4
In this context, the role of the nursing team stands out because, in addition to exercising a leadership role in the administration and control of pharmacological therapy, the complexity of pediatrics requires greater depth of knowledge and the commitment of the professional to carry out the process. However, despite the law of professional practices that proclaims that nurses must perform the most complex practices, in daily practice it has been observed that nurses, technicians and nurse assistants have similar attributions in pharmacological therapy. 5
The absence of quality in this process, with the consequent problems and adverse events, can be avoided with proactive and preventive interventions of hospital administration. Among these interventions, it is worth mentioning the nursing team in relation to knowledge about the drug administration process as an important factor in preventing medication errors, with a view to improving patient safety. 4.7
The first step to preventing errors that affect health is to admit that it is possible and, from this, that professionals understand the types of adverse events, their causes, consequences and factors that contribute to these adverse events. The reporting and recording of adverse events serve as elements for critical analysis and decision-making, processes that aim to eliminate, avoid and reduce these circumstances in daily medical care. 9
To support and improve this practice, it is necessary to know how the nursing team works in drug administration in neonatal and pediatric intensive care units, as well as the circumstances in which errors occur. This research can offer subsidies to professionals to allow an extended analysis of the practice and the problems that permeate this process and, consequently, favor the design of actions that improve the quality of care and safety for all involved.
Therefore, this study aims to investigate the practice of nursing professionals in the medication administration process, as well as the circumstances that lead to errors in neonatal and pediatric intensive care units.
METHOD
This is a descriptive and exploratory study, with a quantitative approach, conducted with the nursing team of the neonatal and pediatric Intensive Care Units of an important hospital in Belo Horizonte, Minas Gerais.
Data were collected between August and November 2017, in morning, afternoon and evening shifts, on random days and contemplating six shifts per week. The study included all nurses, technicians and nurse assistants working in the respective units, so a sample of 147 professionals was reached. The following exclusion criteria were considered: professionals who were on vacation and on medical or maternity leave during the data collection period. A questionnaire was developed based on the recommendations of the Guidelines for the Prevention of Infections Related to Intravascular Catheters 10 and was raised to the pre-trial phase with three specialist nurses, who indicated different suggestions for adjusting the instrument.
The instrument was divided into two parts: Part I was related to the characterization of the sociodemographic profile, where variables such as sex, age, time of exercise in the sector and profession, postgraduate training for nurses, working day and work shift, type of employment contract and participation in courses and conferences on the medication administration process were addressed. Part II included 14 questions that considered how often actions were initiated during the drug delivery process. Four alternatives were included for each action: always, sometimes, rarely or never; The participant had to indicate the correct option. In relation to the circumstance of the errors, 5 questions with various answers were included. These include questions about the types of errors, the circumstances that led to the errors, doubts in the medication process, actions related to the errors, and who to turn to in the event of an error.
The data were written without a spreadsheet in the Microsoft Excel 2010 program, with double typing. They were analyzed in the software StatisticalPackage for the Social Sciences (SPSS) version 19, using descriptive statistics with absolute and relative frequencies for categorical variables and measures of central trends (median) and dispersion for numerical variables.
The study respected the recommendations regarding privacy and confidentiality of Resolution No. 466, dated October 12, 2012, National Council for Scientific Research with Human Beings, and was approved by the Ethics and Research Committee of the Federal University of Minas Gerais and by the institution specialized in the field of study with the written opinion number 1,363,357 and CAAE number: 47994215.9.0000.5129. All research volunteers were pre-guided to the objectives and, after agreeing on them, participants signed the Free and Informed Consent Term (FICT) form on two counterparts.
RESULTS
The sample of this study was composed predominantly of nursing technicians between 25 and 68 years of age (median of 39 years), mostly women, with between 1 and 40 years of training (median of 12), who worked mainly in the Neonatal ICU, with a work regime of 12 hours per day/during the day and with a single and legally governed employment relationship.
Of the 24 nurses, two (8.3%) have a Master’s degree and 21 (87.5%) have a specialization. Among the professionals with specialization, 12 (57.1%) are related to pediatrics and neonatology, and nine (42.85%) to other areas. Table 1 shows the profiles of the professionals.
Table 1. Professional profile corresponding to the nursing team of neonatal and pediatric ICUs (N = 147). Belo Horizonte, MG, Brazil, 2017.
Of the professionals who participated in the research, 51 (34.7%) indicated that they had participated in courses or conferences on the drug administration process between October 2016 and October 2017, while 94 (63.9%) stated that they had not done so during this period.
When asked if the nursing team had already made any mistakes in the medication preparation and administration process, 69 (46.9%) of the professionals answered yes, while 71 (48.3%) said no. Table 2 shows the descriptive analyses corresponding to the quantitative variables related to errors in drug preparation and administration.
Table 2. Frequency in relation to doubts and circumstances of errors when preparing and administering drugs. Belo Horizonte, MG, Brazil, 2017.
In relation to the conduct of professionals, when there was a delay in the administration schedule, 119 (81.0%) professionals said they administered the medication late, while 2 (1.4%) said they missed the schedule and 3 (2.0%) that they advanced the next administration. In addition, upon detecting an error in the medical prescription, 96 (65.3%) responded that they notified the nurse or the nursing coordination area, 90 (61.2%) notified the physician, and 1 (0.7%) participant stated that they tried to resolve it on their own. Table 3 shows the analyses related to the practice of professionals during the preparation and administration of drugs.
Table 3. Frequency of actions performed by professionals in the process of drug preparation and administration. Belo Horizonte, MG, Brazil, 2017.
DISCUSSION
The preparation and administration of drugs is a complex process in which nursing professionals have the important function of being the last barrier to avoid possible drug-related damages in the patient. Consequently, this study aimed to clarify that, through the analysis of the practice and circumstances of the errors, it is possible to propose more effective strategies to promote a culture of safety for the patient, by providing a more qualified and effective care.
Due to the unique nature and complexity of neonatology and pediatrics-oriented therapy, it is extremely important to deepen scientific knowledge and frequent training in such topics. 5 In opposition to this recommendation, this study noted that 63.9% of the study subjects indicated that they did not participate in courses or conferences on drug preparation and administration in the last year and that most have doubts regarding the action of the drugs, doubts that they resolve with their colleagues and not with the consulting nurse. Consequently, it is suggested that, to provide safe and quality care, it is necessary that work processes be reviewed based on scientific evidence and that professionals are trained and properly qualified, both leaders and those who carry out their orders. Educational strategies, mediated by focus groups or educational websites and didactic simulation games, have proven to be important interventions to reduce drug-related incident rates. 11.12
The main medication error mentioned by the professionals who participated in the study was that related to doses, which corroborates a study conducted in the United States with 120 patients in which it was shown that half of them were exposed to medication errors, and that most of the errors were linked to the dose. It should be noted that the main factor contributing to dose error in this study is the complexity and specificity of drug therapy in neonatology and pediatrics. 9,13 In the medical literature, there is evidence of a high prevalence of errors in medical prescription, more prevalent in drugs that want weight-based dosing and, therefore, it is necessary to develop a specific prescription instrument for pediatrics and neonatology, in addition to influencing the agreement of the measures taken when errors have been detected. 14
In relation to the reasons that contribute to medication error, environmental factors, such as poor lighting and inadequate physical conditions, constitute the highest percentage of the sample, followed by communication problems, which is corroborated by other studies. 15,16 It is verified that medication errors are due to the lack of preparation and knowledge of professionals, to the overload and stress generated in the work environment and to communication problems between the multidisciplinary team. It is also emphasized that it is common to suspend the administration of drugs and that the doctor who stopped it did not inform the nursing team. 15 The Food and Drug Administration (FDA) evaluated reports of fatal drug errors and found that 16% of the causes of such errors were attributed to communication problems. Consequently, prescribing is an important link in written communication between health professionals, and is seen as the beginning of a series of events within the medication process, which will lead to the safe administration of a dose to the patient. 17
Effective communication is another important factor in promoting patient safety in drug delivery, present in all interpersonal relationships, and is directly linked as a cause or contributing factor to most incidents. Adequate communication between professionals and patients and/or caregivers in relation to drug administration provided relevant and effective results, thus avoiding the occurrence of new incidents. 18
In relation to the incidence of errors, it is important to note that, from the recognition of an error, it is necessary to analyze the entire process and the components of the medication system, which can contribute or act as a barrier to overcome the error. These errors can be attributed to professionals, system failures, the institution or even the presentation of drugs. This analysis is indispensable to understand all the factors involved in the medication process, without attributing the failures to the incompetence or irresponsibility of employees. (1t)
In relation to the behavior of the professional in the face of error, most of the interviewees indicated that they notified the nursing coordination area, a fact that diverges from other studies. In a survey conducted in South Florida, it was found that 57.9% would not report an error if they thought it was not dangerous and 25% would not report it for fear of the consequences. The perception of the nursing staff regarding medication errors is that only 45.6% are reported; The rest is omitted for fear of reaction from leaders and colleagues. 19 The treatment given to error notifications with emphasis on staff performance contributes to the non-reporting of all errors, since professionals are afraid to respond to legal and administrative processes, to be labeled as negligent, to lose the trust of the administrator and his teams. It is a worrying reality that must be reversed because not reporting all errors prevents analyzing them and developing possible measures that minimize their frequency and guarantee patient safety.
Studies that problematize the cultural change in the approach to incidents related to patient safety have shown that an intervention specifically focused on this issue for professionals significantly reduces medication errors. In addition, political change in institutions is needed. 18
One of the main problems identified by the participants of this research was the interruption during the preparation of the drugs, which is included in the research as a critical point that leaves professionals more vulnerable to making a mistake, because they are exposed to distractions. In a study conducted with pediatric nurses, it was shown that the result was negative in 88.9% of the observed interruptions. Consequently, one study suggests that it is necessary to create restricted areas to prepare drugs, and thus avoid interference. 20
Double-checking is an effective method of eliminating errors in drug delivery. 15,16 In this study, the nursing team reported that this practice is scarce or practically nonexistent. In addition, there were cases where the drugs were administered by another person and cases where the drugs were not checked against the prescription before administration, which runs counter to good practice recommendations related to drug administration. 10
In this study, professionals reported that they follow some of the recommended actions in the safe drug delivery process. However, it should be considered that all practices involving patient safety in the health care process, and not just some, must be adhered to. Ensuring that good practices are adhered to prevents barriers from collapsing to prevent injuries. 10.16
The results presented are directly related to institutional specificities, a fact that limits generalization. Therefore, the relevance of studies with representative samples is highlighted, with the same theme as that of this study, resulting from the scarcity of studies with such design and focus in pediatrics and neonatology.
CONCLUSIONS
The study demonstrated that the practice of drug preparation and administration has significant weaknesses that can jeopardize pediatric patient safety. Consequently, it is pointed out that it is necessary for the team to reflect on the findings so that behavioral changes and safety strategies can occur in order to avoid errors and, consequently, improve patient safety.
In view of the above, the relevance of such results is notorious. In this perspective, continuous team training with emphasis on the specifics of pediatrics and neonatology and the control and evaluation of process indicators are important strategies to avoid errors and adverse events. It is believed that, through these actions, the development and implementation of the safety culture is made possible.
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