Saucedo-Becerra A, Serrano-Flores FE, Flores-Arcos V, Morales-Olarte E, Santos-García A

Language: Spanish
References: 27
Page: 19-26
PDF size: 136.98 Kb.

ABSTRACT

Introduction: At worldwide level mistakes during the administration of intravenous medications are reported, fortunately, are exceptional the number of hazard cases.
Objective: To identify the most frequent mistakes from nursing staff during the administration of intravenous medications in pediatrics in a specialized medical facility.
Methodology: Transversal, observational, and descriptive study. Registered and specialist nurses were studied through a check list meanwhile they were doing a procedure of administration of intravenous medications. Their knowledge was measured through a questionnaire previously validated by expert consensus. Data analysis was done with descriptive statistics.
Results: From 230 procedures, recording errors were identified (43%) in which nursing staff did not make the record immediately after; error when setting up the medication to be administered, meaning as inexact dose (31%). When evaluating the nurses’ knowledge 68% nurses had "efficient" and 32% deficient knowledge.
Discussion: Mistakes during the administration of medications showed a similar performance to that showed in medical literature; however, this study showed that the most frequent mistake was recording because it was done at different times and showed a percentage lightly minor to that referred in the medical literature. The error when setting up the medication had 2% lees to that referred in the medical literature by another author.
Conclusions: In this research errors mean "pseudo fails" type 2 which did not mean to be hazardous to patients; however, it is necessary inclusion of improvements within the organization of services that show up a safer clinical practice.

REFERENCES

1. Editorial. Prevención de errores de medicación. Nursing 1994;12(2):5.

2. Editorial. Precaución en la administración de fármacos en bolo intravenoso. Nursing 1996;10(2):5.

3. Editorial. Realidades de la práctica. Administración del tratamiento i.v. Nursing 1990;8 (1):5.

4. McGovern K. 10 reglas de oro para la administración segura de fármacos. Nursing 1993;11(3):25-32.

5. Byington KC. Guía para la administración de fármacos pediátricos. Nursing 1992; 10(5):59-61.

6. Campino-Villegas A, López-Herrera MC, García-Franco M, López de Heredia-Goya I, Valls I Soler A. Errores en la prescripción y trascripción de medicación en una unidad neonatal. An Pediatr (Barc); 2006; 64(4):330-5.

7. What is a Medication Error? [En línea] http://www.nccmerp.org/about Med Errors.html [Consultado 17/11/07]

8. Dean B. Learning from prescribing errors. Qual Saf Health Care 2002; 11(3): 258-60.

9. Muñoz-Labian M, et al. Errores en las prescripciones medicas en una unidad neonatal. An Esp Pediatr 2001; 55(6): 535-40.

10. Rendón-Macías ME, Heyser-Ortíz SE, Reyes-Zepeda NC. Índice de anotaciones médicas equivocadas. Efecto de la periodicidad en la actualización. Rev Med IMSS 2002; 40(4):285-291.

11. Birne K. Errors in given medication. Am J Nurs 1953; 53(7):829-31.

12. Hershey N. The law and the nurse. Question that drug order: the court lays down the law. Am J Nurs 1963; 63:96-7.

13. Kern MS. New ideas about drug systems. Am J Nurs 1968; 68(6):1251-3.

14. Perlstein PH, Callison C, White M, Barnes B, Edwards NK. Errors in drug computations during newborn intensive care. Am J Dis Child 1979; 133(4):376-9.

15. Raju TN, Kecskes S, Thornton JP, Perry M, Feldman S. Medication errors in neonatal and paediatric intensive-care units. Lancet 1989; 2(8659):374-6.

16. Aneja S, Bajaj G, Mehandiratta SK. Errors in medication in a pediatric ward. Indian Pediatr 1992; 29(6):727-30.

17. Rheinstein PH, McGinnis TJ. Medication errors. Am Fam Physician 1992; 45(6): 2720-2.

18. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). NCC MERP Taxonomy of Medication Errors. [en línea] http://www.nccmerp.org/pdf/taxo 2001-07-31. pdf [Consultado 15/04/05]

19. Borel JM. Rascati KL. Effect of an automated, nursing unit-based drugdispensing device on medication errors. Am J Health Syst Pharm 1995; 52(17): 1875-9.

20. Tosta de Carvalho V, De Bortoli Cassiani SH. Errores en la administración de medicamentos: análisis de situaciones relatadas por los profesionales de Enfermería. Rev Invest Educ Enferm 2001; 19(2) [en línea] http://tone.udea.edu.co/revista [Consultado 15/04/05]

21. Cohen MR. Help new nurses avoid making errors. Nursing 1992; 22(4):21.

22. El exceso de trabajo contribuye a un incremento en el numero de errores en la administración de medicamentos [en línea] http://www.anec.org.co/revista/articulos.htm?x=26226&cmd [111]=c-1-61 [Consultado 15/04/05]

23. Simpson JH. Lynch R. Grant J. Alroomi L. Reducing medication errors in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed. 2004; 89(6): F480-2.

24. Marcial L Back. Preventing medication errors en children's medical center. Pediatric Pharmacotherapy 1999. 5(10) [en línea] www.healthsystem.virginia.edu/internet/pediatrics/pharma-news/Oct99.PDF [Consultado 15/04/05]

25. Nashef SA. What is a near miss? Lancet 2003; 361(9352):180-1.

26. Wakefield BJ, Wakefield DS, Uden-Holman T, Blegen MA. Nurses' perceptions of why medication administration errors occur. Medsurg Nurs 1988; 7(1): 39-44.

27. Cohen MR. Flutamide or thalidomide. Nursing 2004; 34(6):18.