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Ana Isabel Maia de OliveiraIvonete Batista de Araújo erros de Prescrição em Uma Unidade de tratamento erros de Prescrição em Uma Unidade de tratamento resUmo
Objetivos: Avaliar o índice de erros de prescrição nas prescrições médicas dos pacientes admitidos em
uma unidade de terapia intensiva (UTI), o grupo de medicamentos mais relacionados aos erros de prescrição e o índice de aceitação das sugestões farmacêuticas.
Métodos: as prescrições médicas dos pacientes admitidos na UTI de um hospital universitário foram
analisadas. Os parâmetros considerados foram dose, intervalo de administração, via de administração, velocidade de infusão e diluição dos medicamentos. Os medicamentos mais relacionados aos erros de prescrição também foram avaliados, assim como a aceitação das sugestões farmacêuticas.
Resultados: 741 prescrições foram analisadas e 480 (64,78%) foram incluídas no estudo. 374 erros de
prescrição foram encontrados após a análise da prescrição de 5007 medicamentos, o que resultou num índice de erro de 7,47%. 41,67% das prescrições médicas continham pelos menos um erro e o erro no intervalo de administração foi o mais comum (35,56% do total de erros). Os antimicrobianos foram os medicamentos mais relacionados aos erros de prescrição. O farmacêutico realizou 152 sugestões de modificação das prescrições, das quais 98,03% foram aceitas pelos médicos prescritores.
Conclusão: os erros de prescrição são eventos comuns na UTI estudada, trazendo um risco em potencial
para os pacientes. O erro no intervalo de administração foi o tipo de erro mais freqüente nesse estudo. Os antimicrobianos foram os medicamentos mais relacionados aos erros. A aceitação às sugestões foi elevada.
Descritores: Erros de Medicação, Terapia Intensiva, Atenção Farmacêutica.
abstract
Purpose: To evaluate the rate of prescribing errors in the prescribing orders of patients admitted to
an intensive care unit (ICU), the medication groups more related to the prescribing errors and the rate of acceptance of pharmacist intervention.
Methods: The prescriptions charts of patients admitted to the ICU of a teaching hospital in Brazil were
analyzed. The considered parameters were dose, dosing interval, route of administration, infusion time and dilution of medications. The most common medications related to the errors were also evaluated, as well the acceptance of the interventions made by the pharmacist. Results: A total of 741 prescriptions charts were analyzed and 480 (64.78%) were included in the study.
374 prescription errors were found after the analysis of 5007 medication orders, which resulted in a error rate of 7.47%. 41.67% of the prescriptions charts had at least one error and the dosing interval error was the most common (35.56% of the errors). The antibiotics were the medications more related to the prescribing errors. The pharmacist made 152 interventions and 98.03% of these were accepted by the physicians. Conclusion: The prescribing errors are common occurrences in the studied ICU, bringing potential risk to the
patients. The dosing interval error was the most frequent type of error found in the study. The systemic antibiotics were the medication group more related to the errors. The acceptance of pharmacist intervention was high.
Keywords: Medication errors, Intensive care, Pharmaceutical care.
resÚmen
Objetivos: Evaluar el índice de errores en la prescripción de medicamentos en las recetas de pacientes
ingresados en una unidad de cuidados intensivos (UCI), evaluar el grupo de medicamentos más relacionados a los errores de prescripción y el índice de aceptación de las sugerencias realizadas por el profesional Metodología: Se analizaron las prescripciones de los ingresados a la UCI de un hospital universitario. Los
parámetros considerados fueron: la dosis, el intervalo de administración, la vía de administración, la velocidad de infusión y la dilución de los medicamentos. También se evaluó cuales son los medicamentos más relacionados a los errores de prescripción y la aceptación de las sugerencias farmacéuticas realizadas al prescriptor.
Rev Bras Farm Hosp Serv Saúde. São Paulo v.3 n.3 6-10 jul./set. 2012 Resultados: 741 prescripciones fueran analizadas y un total de 480 (64,78%) fueran incluidas en el estudio. Tras analizar la prescripción de 5007 medicamentos,
se encontraron 374 errores de prescripción, por ende el índice de error en la prescripción fue de 7,47%. Un 41,67% de las prescripciones contenían por lo menos un error. El error más recurrente se observó en el intervalo de administración (35,56%). Los antimicrobianos fueron los medicamentos más relacionados a los errores de prescripción. El farmacéutico realizó 152 sugerencias de modificación en las prescripciones, de las cuales un 98,03% fueron aceptadas por los prescriptores.
Conclusión: Los errores de prescripción son eventos recurrentes en la UCI estudiada, lo que representa un riesgo potencial en los pacientes
hospitalizados en ella. El error en el intervalo de administración fue el error más frecuente en este estudio. Los antimicrobianos fueron los fármacos más relacionados a errores de prescripción. La aceptación de las sugerencias fue elevada.
Descriptores: Errores de Medicación, Cuidados Intensivos, Atención Farmacéutica.
the literature, in an inappropriate dose for patients with renal or hepatic failure or the lack of the dose in a prescribing order.
The medication process includes, at least, the prescription, the Dosing Interval Error: the prescription of a medication in a dosing dispensation and the administration of a medication. It is, therefore, interval not reported in the literature, in an inappropriate dosing interval a complex and multidisciplinary activity that involves physicians, for patients with renal or hepatic failure or the lack of the dosing interval pharmacists, nurses and other healthcare professionals(1-2).
Medication errors, defined as a failure in the treatment process that Route of administration error: the prescription of a medication leads to, or has the potential to lead to, harm to the patient, are common in a route of administration not recommended by the literature, the occurrences in the medication process, affecting especially inpatients(3). prescription of a medication in an unsafe route or the lack of the route of These errors affect between 4% and 17% of inpatients and are considered administration in a prescribing order.
the major cause of harm to this population. They bring important clinical Infusion time error: the prescription of a medication in an infusion and economic implications, endangering patient safety and raising time not reported in the literature or the lack of the infusion time in a prescribing order for medications that induce toxicity or therapeutic The ICU is the site of most medication errors in the hospital response according to this parameter.
environment, which can be due the severity of illness of its patients, the Dilution error: the prescription of an inappropriate dilution for an prescription of a great number of medications and the stressful work injectable medication or the lack of the dilution in the prescribing order environment(5). The consequences of the errors are also more serious in critical care patients. Nearly 19% of medication errors in ICU are life- Each error rate was calculated using the following equation: threatening and 42% create the need for additional treatment(6).
Rate of a type of error = (number of errors per type / total number The pharmacist participation in the ICU is one of the strategies that can be adopted to prevent medication errors, as this healthcare professional Medication groups more related to errors. The analyzed medications provides important information that makes the medication use safer(7-8).
were divided in groups according the Anatomical Therapeutic Chemical The main objective of this study was to evaluate the rate of prescribing (ATC) classification. This allowed the identification of medication errors in the prescribing orders of patients admitted to an ICU, the groups more related to the errors. The error rate per medication group medication groups more related to the prescribing errors and the rate of was calculated using the following equation: acceptance of pharmacist interventions.
Rate of error per medication group = (number of group errors / total Acceptance to pharmacist intervention. The pharmacist made interventions on the errors found from 7:00 am to 5:00 pm. The Study design. Cross-sectional, quantitative, descriptive and interventions that resulted in the immediate change of the prescribing prospective study that was carried out in the ICU of a brazilian teaching order were considered accepted. The rate of acceptance was calculated hospital. The referred ICU has 12 beds and receives patients from clinical Rate of acceptance = (number of accepted interventions / total Ethical considerations. The study was authorized by the ethics committee of the university that manages the hospital. For each patient, a close relative signed an informed consent after explanations about procedures and importance of the research. Only the prescription charts of patients whose relative signed the informed consent were included in the study. A total of 741 prescriptions charts were analyzed and 480 (64.78%), Data collection and statistical analysis. The data was collected corresponding 5007 prescribing orders, were included in the study, as during 92 days (May 15th to August 15th) from the 7:00 am to 5:00 pm. they fulfill the inclusion criteria. At least one prescribing error was found During this period, each prescribing order was analyzed and the data in 41.67% (200/480) of the prescription charts. Table 1 shows the rates was registered. The medications prescribed out of the daily period of of the number of errors per prescription.
collection were evaluated on the next day. The Microsoft Excel 2007 was used to calculate the rate of error.
Table 1 - Total Number and Rates of Errors per Prescription Inclusion criteria. The prescription charts of patients which a close relative signed the informed consent.
Number of Errorsper Prescription Number of Prescriptions Exclusion criteria. The prescription charts of patients which a close relative did not sign the informed consent were not included. The electrolyte solutions and insulins, as well as, the dermatologic and inhaled medications were also not included in the study.
Parameters and errors. The analyzed parameters on the prescribing orders were dose, dosing interval, route of administration, infusion time and dilution of medications. Any difference between the prescription orders and the literature of reference (MICROMEDEX®,(9) UptoDate®,(10)“Handbook of Injectable Drugs”)(11)was considered an error. The following types of error were evaluated: Dose error: the prescription of a medication in a dose not reported in Rev Bras Farm Hosp Serv Saúde. São Paulo v.3 n.3 6-10 jul./set. 2012 The prescribing error rate was 7.47% (374/5007). The dosing interval A total of 68 medications were related to prescribing errors and they error had a rate of 35.56% (133/374), while route of administration were divided according to the main ATC group. The error distribution by errors corresponded to 26.74% (100/374) of total number of errors. The main ATC group can be seen in Table 2, while Table 3 shows the most dose errors, dilution errors and infusion time errors had a rate of 12.57%, common medications in each ATC group.
Table 2- Error Distribution by Main ATC Group Alimentary Tract and Metabolism (Group A) Genito Urinary System and Sex Hormones (Group G) Systemic Hormonal Preparations, Excl. Sex Hormones and Insulins (Group H) Antiinfectives for Systemic Use (Group J) Antiparasitic Products, Inseticides and Repellents (Group P) Table 3 - Medications More Related to Prescribing Errors in Each ATC Group Alimentary Tract and Metabolism (Group A) Systemic Hormonal Preparations, Excl. Sex *Rates corresponding to the total number of errors (374).
The pharmacist made interventions in 152 prescribing orders, which study developed in an important hospital in Brazil found an error rate of corresponds to 40.64% (152/374) of the total number of prescribing 9.2%(18). The methodological differences make the comparisons to the errors. The rate of acceptance to pharmacist intervention was 98.03%, as only three interventions were not accepted.
At least one prescribing error was found in 41.67% (200/480) of the prescription charts analyzed in the present study. This finding can be related to the presence of residents in the ICU. In fact, other studies The comparison between medication errors studies is a difficult showed that these professionals commit more prescribing errors, task, as definitions and methodologies used are widely variable. Thus, especially at the start of the rotations(19).
comparison between different institutions can be misinterpreted by The dosing interval error was the most common type of error, confounding variables, as the individual prescribing practices(12-13).
corresponding to 35.56% (133/374) of the total number of errors. The Although comparison difficulties, the rate of prescribing errors found ICU that hosted this study receives a great number of patients with in this study (7.47%) is similar to the findings of other studies, including renal dysfunction, which requires the adjustment of the dosing interval the systematic review of Lewis et al., which reported an error rate of of many medications. However, this procedure was not taken in a great 7%(14-15). Of note, in these studies, the analyzed prescribing orders were number of prescribing orders and the parameter was adjusted only after handwritten by the physicians, while the orders analyzed on this study were made using an electronic prescribing system. Regarding to this type The route of administration error represented 26.74% (100/374) of of prescribing system, the study of Shawahna et al.(16)found an error rate total number of errors and was the second most common. A great part of of 8.2% after the introduction of this technological support.
these occurrences was related to the prescription of medications by oral The studies about medication errors in Brazil are still scarce(17). route, while the patient was using a nasoenteral tubes for administration However, the study of Bohomol, Ramos and D’Innocenzo identified 305 of medications and enteral nutrition.
medication errors in an ICU, of which 4.6% were prescribing errors. A The dosing error was the third more common type of error found Rev Bras Farm Hosp Serv Saúde. São Paulo v.3 n.3 6-10 jul./set. 2012 in the study, corresponding to 12.57% (47/374). This finding differs patients. The dosing interval error was the most frequent type of error from the data found in the literature, which points to this error as the found in the study. The systemic antibiotics were the medication group most common type of prescribing error(13, 16, 20). Most of these errors were more related to the errors. The acceptance of pharmacist intervention related to the prescription of conventional doses for patients of renal was high and the integration of this healthcare professional in the ICU multidisciplinary team can decrease the frequency of the prescribing The dilution errors represented 12.03% (45/374) of errors. An errors and, therefore, increase the patient safety.
important example of this type of error was the lack of this parameter on the prescribing orders of some antibiotics, such as amikacin, clindamycin and trimethoprim/sulfamethoxazole (co-trimoxazole). It is known that these medications can produce important adverse reactions if 1. Aronson JK. Medication errors: definitions and classification. Br J Clin Pharmacol. 2009 Jun;67(6):599-604.
The infusion time error corresponded to 13.10% (49/374) of errors. The not addition of this parameter on the prescribing orders of 2. Camire E, Moyen E, Stelfox HT. Medication errors in critical antibiotics, such as vancomycin, cefepime and meropenem, was the care: risk factors, prevention and disclosure. CMAJ. 2009 Apr most common occurrence for this type of error. It is known that the infusion of the glycopeptide in less than one hour can produce the red man syndrome(11). Regarding to the two beta-lactams, recent studies have 3. Ferner RE. The epidemiology of medication errors: the methodolo- shown a greater probability of treatment success if they are infused in gical difficulties. Br J Clin Pharmacol. 2009 Jun;67(6):614-20.
The systemic antibiotics (Group J of ATC classification) were the 4. Pinilla J, Murillo C, Carrasco G, Humet C. Case-control analysis of medication group more related to the prescribing errors, with 32.89% the financial cost of medication errors in hospitalized patients. Eur J (123/374) of total number of errors. This finding is also shown in other studies, including those in ICU(13, 23). The meropenem and the cefepime were the medications of the group with more prescribing errors, 9.36% 5. Bohomol E, Ramos LH, D’Innocenzo M. Medication errors in an (35/374) and 7.75% (29/374), respectively. These are the most used intensive care unit. J Adv Nurs. 2009 Jun;65(6):1259-67.
antibiotics in the ICU that hosted this study, which can justify this finding.
The medications that act in the nervous system (Group N of ATC 6. Moyen E, Camire E, Stelfox HT. Clinical review: medication errors classification) also presented a strong relation with the prescribing in critical care. Crit Care. 2008;12(2):208.
errors, with a rate of 28.88% (108/374). In this group, the fentanyl was the medication with more errors, with a rate of 5.88% (22/374). Some 7. Francke DE. The interdisciplinary nature of medication errors. Ann studies show a high rate of prescribing errors with opioids(15). Many prescribing errors occurred after 5:00 pm, making the pharmacist intervention impossible. Nevertheless, the acceptance of 8. Hughes CF. Medication errors in hospitals: what can be done? Med pharmacist intervention was high, with a rate of 98.03% (149/152). The studies of Leape et al.,(24)Zaidi et al.(25)and Kopp et al.(26)also found a high acceptance, with rates of 99%, 95% and 98%, respectively. These results 9. Micromedex®. Healthcare Series [Internet database]. Greenwood suggest that the pharmacist integration in the ICU multidisciplinary team Village, Colo: Thomson Reuters (Healthcare) Inc. Updated perio- reduces the prescribing errors and, therefore, raises the patient safety. The role of this healthcare professional can be even more important, with improvement of clinical and economical outcomes(14, 23). 10. ROSE BDR, J., editor. UpToDate® Inc. Disponível em: www.upto- The electronic prescribing system used in the ICU requires the definition of the dosage form, dose, dosing interval and route of administration. Regarding to intravenous formulations, the dilution 11. Trissel LA. Handbook of Injectable Drugs. 15ed ed. Bethesda: is suggested by the system, but can be modified by the physician. The American Society of Health-System Pharmacists; 2009.
infusion time is an optional parameter that can be added as a complement to the prescribing order. The results found in the present study may have 12. Franklin BD, Reynolds M, Shebl NA, Burnett S, Jacklin A. Prescri- been influenced by this technological resource, as several studies show a bing errors in hospital inpatients: a three-centre study of their preva- reduction of the prescribing errors after its introduction(27-29).
lence, types and causes. Postgrad Med J. 2011 Nov;87(1033):739- Although the prescribing orders are made in the electronic system, the handwritten additions still occurs during the day, which generates a new opportunity for error. In fact, many prescribing errors were 13. Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. committed during this practice. This reinforces the evidence that the Prevalence, incidence and nature of prescribing errors in hospital electronic prescribing systems reduce the errors.
inpatients: a systematic review. Drug Saf. 2009;32(5):379-89.
Some limitations must be considered in the present study. The prescribing orders were analyzed by only one pharmacist and previous 14. Al-Dhawailie AA. Inpatient prescribing errors and pharmacist in- studies suggest that can be variability in the error detection according tervention at a teaching hospital in Saudi Arabia. Saud Pharm J to the reviewer pharmacist(30). The pharmacist interventions were performed in only 40.64% of the prescribing errors, which may have resulted in an overrated rate of acceptance. The severity of the prescribing 15. Denison Davies E, Schneider F, Childs S, Hucker T, Krikos D, Peh errors was not analyzed, which makes the evaluation of actual risk for the J, et al. A prevalence study of errors in opioid prescribing in a large teaching hospital. Int J Clin Pract. 2011 Sep;65(9):923-9.
16. Shawahna R, Rahman NU, Ahmad M, Debray M, Yliperttula M, Decleves X. Electronic prescribing reduces prescribing error in The prescribing errors are common occurrences in the ICU of the public hospitals. J Clin Nurs. 2011 Nov;20(21-22):3233-45.
teaching hospital that hosted this study, bringing potential risk to the Rev Bras Farm Hosp Serv Saúde. São Paulo v.3 n.3 6-10 jul./set. 2012 17. Miasso AI, Oliveira RC, Silva AEBC, Lyra Júnior DP, Gimenes FRE, Fakih FT, et al. Prescription errors in Brazilian hospitals: a multi- -centre exploratory survey. Cad Saúde Pública. 2009;25(2):313-20.
18. Silva AMS. Erros de prescrição médica de pacientes hospitalizados. 19. Lesar TS, Briceland LL, Delcoure K, Parmalee JC, Masta-Gornic V, Pohl H. Medication prescribing errors in a teaching hospital. Jama. 20. Velo GP, Minuz P. Medication errors: prescribing faults and pres- cription errors. Br J Clin Pharmacol. 2009 Jun;67(6):624-8.
21. Cheatham SC, Shea KM, Healy DP, Humphrey ML, Fleming MR, Wack MF, et al. Steady-state pharmacokinetics and pharmacodyna- mics of cefepime administrered by prolonged infusion in hospitali- sed patients. Int J Antimicrob Agents 2010.
22. Lee LS, Kinzig-Schippers M, Nafziger AN, Ma L, Sorgel F, Jones RN, et al. Comparison of 30-min and 3-h infusion regimens for imi- penem/cilastatin and meropenem evaluated by Monte Carlo simu- lation. Diagn Microbiol Infect Dis. 2010;68:251-8.
23. Klopotowska JE, Kuiper R, van Kan HJ, de Pont AC, Dijkgraaf MG, Lie AHL, et al. On-ward participation of a hospital pharmacist in a Dutch intensive care unit reduces prescribing errors and related patient harm: an intervention study. Crit Care. 2010;14(5):174-84.
24. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Eri- ckson JI, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999 Jul 25. Zaidi ST, Hassan Y, Postma MJ, Ng SH. Impact of pharmacist re- commendations on the cost of drug therapy in ICU patients at a Malaysian hospital. Pharm World Sci. 2003 Dec;25(6):299-302.
26. Kopp BJ, Mrsan M, Erstad BL, Duby JJ. Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. Am J Health Syst Pharm. 2007 Dec 1;64(23):2483-7.
27. Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. J Am Med Inform Assoc. 2008 Sep- 28. Hartel MJ, Staub LP, Roder C, Eggli S. High incidence of medi- cation documentation errors in a Swiss university hospital due to the handwritten prescription process. BMC Health Serv Res. 29. Went K, Antoniewicz P, Corner DA, Dailly S, Gregor P, Joss J, et al. Reducing prescribing errors: can a well-designed electronic system help? J Eval Clin Pract. 2010 Jun;16(3):556-9.
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