ORIGINAL ARTICLE. English/Portuguese J Nurs UFPE on line., Recife, 11(Suppl. 5): , May.,

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1 ERROS NO PROCESSO DE MEDICAÇÃO: PROPOSTA DE UMA ESTRATÉGIA EDUCATIVA BASEADA NOS ERROS NOTIFICADOS ERRORS IN THE MEDICATION PROCESS: PROPOSAL OF AN EDUCATIONAL STRATEGY BASED ON NOTIFIED ERRORS ERRORES EN EL PROCESO DE MEDICACIÓN: PROPUESTA DE UNA ESTRATEGIA EDUCATIVA BASADA EN LOSERRORES NOTIFICADOS Mayra Gonçalves Menegueti 1, Livia Maria Garbin 2, Marília Pilotto de Oliveira 3, Camila Megumi Naka Shimura 4, Caroline Guilherme 5, Rosalina Aparecida Partezani Rodrigues 6 ABSTRACT Objectives: to characterize errors in the medication process reported through the electronic system of a large general hospital and propose an educational and problematizing strategy in order to minimize the occurrence of this type of adverse event. Method: a descriptive, quantitative approach. The data was collected from the error notification sheets in the medication process. Results: the sample consisted of 214 notifications. Adverse events were, mostly, errors (n = 204, 95.3%), occurred at the morning shift (n = 106, 49.4%) and were classified as prescription errors (n = 164, 76.6%). Conclusion: this study found, as main errors, those related to prescription of drugs, which, was often identified early and, in few cases, caused harm to the patient. Descriptors: Medication Errors; Medication System; Quality of Health Care; Patient Safety. RESUMO Objetivos: caracterizar os erros no processo de medicação notificados por meio do sistema eletrônico de um hospital geral de grande porte e propor uma estratégia educativa e problematizadora com o intuito de minimizar a ocorrência deste tipo de evento adverso. Método: estudo descritivo, de abordagem quantitativa. Os dados foram coletados a partir das fichas de notificação de erros no processo de medicação. Resultados: a amostra foi composta por 214 notificações. Os eventos adversos foram, em sua maioria, erros (n = 204, 95,3%), ocorreram no plantão da manhã (n = 106, 49,4%) e foram classificados como erros de prescrição (n = 164, 76,6%). Conclusão: este estudo encontrou, como principais erros, os relacionados à prescrição de medicamentos que, muitas vezes, foram identificados precocemente e, em poucos casos, causaram dano ao paciente. Descritores: Erros de Medicação; Sistemas de Medicação; Qualidade da Assistência à Saúde; Segurança do Paciente. RESUMEN Objetivos: caracterizar los errores en el proceso de medicación notificados a través del sistema electrónico de un gran hospital general y proponer una estrategia educativa y problematizada con el fin de minimizar la ocurrencia de este tipo de evento adverso. Método: estudio descriptivo de un enfoque cuantitativo. Los datos fueron obtenidos de la notificación de errores en el proceso de medicación. Resultados: la muestra estaba compuesta por 214 notificaciones. Los eventos adversos fueron, en sus mayoría, errores (n = 204, 95,3%) estaban de turno en la mañana (n = 106, 49,4%) y fueron clasificados como errores de prescripción (n = 164, 76.6%). Conclusión: este estudio encontró, los principales errores, relacionados con los medicamentos de prescripción, que, a menudo fueron identificados temprano no generando daños al paciente. Descriptores: Errorers de Medicación; Sistemas de Medicación; Calidad de la Atención de Salud; Seguridade del Paciente. 1 Nurse, Doctorate student in Nursing, Nurse of the Control and Hospital Infection Commission of the Clinic Hospital, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto (SP), Brazil. mayramenegueti@usp.com.br; 2 Nurse, PhD in Nursing, Nurse at the University of São Paulo at Ribeirão Preto College of Nursing EERP / USP. Ribeirão Preto (SP), Brazil. liviagarbin@usp.br; 3,4,5 Nurses, PhD in Nursing. Ribeirão Preto (SP), Brazil. mariliapilotto@gmail.com; camilamegumi@usp.br; carolgufrj@gmail.com; 6 Nurse, PhD in Nursing, Professor, School of Nursing of Ribeirão Preto, University of São Paulo / EERP / USP. Ribeirão Preto (SP), Brazil. E- mail: rosalina@eerp.usp.br ORIGINAL ARTICLE J Nurs UFPE on line., Recife, 11(Suppl. 5): , May.,

2 INTRODUCTION With increasing concern with improving health care, the patient's safety during hospitalization has been increasing. 1-2 Health care institutions must provide care to patients with the lowest possible risks. However, some situations predispose the occurrence of adverse events, such as: technological advancement, with deficits in the improvement of professional staff, demotivation, work overload, delegation of care to patients without adequate supervision, inexperience, communication failure, poor infrastructure, cultural factors and absence or limitation of the documentation of care provided. 2-3 An adverse event refers to any undesirable occurrence, which may be related to the use of a pharmaceutical product, but does not necessarily have a causal relationship with the treatment, and must be recorded in the patient's medical record and, optionally, in a specific book. 4 Among the adverse events are errors related to the medication process. A medication error is characterized by any preventable event that may impair or induce the inappropriate use of a medication or harm the patient while the medication is under the control of a health care provider, patient, or consumer. It is also necessary to consider that the drug administration system is a multidisciplinary process. These events may be related to professional practice, products, procedures and health care systems, including prescription, communication, labels, packaging and product nomenclature, as well as composition, preparation, distribution, administration, education, monitoring and use of the same 5, and can occur in any of the stages and involve several professionals. The occurrence of errors, at any stage of the process, is not only undesirable, but detrimental to the patient as well as to the team and institution. 1 The repercussions for the patients are the most worrisome, since they may have their clinical conditions aggravated, as well as temporary and permanent injuries and even death, 6 being reported, in the literature, that medication errors account for seven thousand deaths, annually in the United States. 7 The mistakes also bring repercussions to the professional involved through legal penalties. These can vary depending on the severity of the bodily injury to the patient and the type of consequence. Professionals may be subject to legal proceedings for negligence, recklessness, bad practice and under civil, criminal and ethical legislation 8 ). Law No , of June 25, 1986, which deals with the exercise of Nursing, includes the attribution of Nursing auxiliaries to the administration of oral and parenteral drugs and as a nurse's activity the supervision of these actions. 9 The Nursing team should collaborate with the safety of the medication system, seeking solutions to existing problems, as well as developing research on this issue. 10 The World Health Organization highlights this issue through the "Patient Safety: A World Alliance for Safe Health Care" Campaign, in which adverse events and drug errors are the sixth priority of research in countries with economies transition as in developed countries, with the purpose of contributing to the promotion of safe patient care. 11 Thus, the implementation of strategies, in order to minimize the occurrence of errors in each of the phases of the process, is the proposal of this study, that aimed to characterize the errors in the medication process notified through the electronic system of a large general hospital and propose an educational and problematizing strategy in order to minimize the occurrence of this type of adverse event. METHOD A descriptive, quantitative study conducted in a large general university hospital, integrated to the Unified Health System, which develops activities focused on teaching, care and research. The hospital is composed of two distinct buildings: one located in the University Campus and another in the central part of the city, destined for emergency and emergency care. These buildings currently have 700 and 200 beds, respectively. For the development of the study, the problem-solving methodology was adopted, which originates in Paulo Freire's studies and consists of a teaching method based on the solution of problems detected in the reality in which the individual is inserted and to the exercise of the dialectical chain of action - reflection-action. Its use starts from the lived reality, where the "problem" is inserted, making the learning is constituted by the careful observation, systematized and critical of the reality to identify the problematizing elements and, through the active research, with the objective of deepen the knowledge and promote the reflection, are identified J Nurs UFPE on line., Recife, 11(Suppl. 5): , May.,

3 which aspects must be worked and where there is possibility of intervention. 12 Thus, the problem-solving methodology provides resources for educational actions to be built and based on the problems experienced during the Nursing administration process, allowing the implementation of strategies to minimize them. The dialectical chain used in the methodology of the problem is composed of five stages, which constitute the "arch method" or "arch scheme". 12 To reach the objectives of this study, four proposed steps have been covered: identification of key points, theorization and solution hypothesis. The fifth step, which corresponds to the application of the hypothesis of solution to reality, is being developed with the Subcommittee on Medication Errors, in partnership with the Patient Safety Committee of the hospital where the study was developed, since it is a gradual process and requires of partnerships with the institution. Data were collected from the adverse event notification forms, specifically those related to errors in the medication process, completed and submitted to the Subcommittee on Medication Errors in the period from January first to June 30 th, An instrument was used to characterize errors in the medication process containing items referring to the information available in the notification sheets themselves, being: date and time of notification, date and time of event, type of event, professional category of the notifier, data of characterization of the patient (gender, age, occurrence of damage to the same), place of occurrence of the error, product involved in the event, possible causes of occurrence of the event and immediate action of the professional who identified the event. This phase corresponded to the reality observation phase, revealing important points of the professionals' reality regarding the aspects related to the drug administration process, as well as the elements that surround the scenario of this situation. Once the data were collected, they were stored in a database built in the Microsoft Excel Program. Double typing was performed and, after validation, they were analyzed using descriptive statistics. From the data, a panorama was drawn in relation to this topic and identified the key points related to the occurrence of errors in the medication process in the institution. In the sequence, the theoretical discussion of the subject and the data was carried out, having as reference works already developed and published in relation to the topics covered, besides the experience of the researchers. After the theorization, an institutional educational strategy was developed, encompassing all the professionals involved in the medication process, such as Nursing professionals, physicians, pharmacists and administrative personnel related to the requisition, dispensation and medication conference. After proposing the strategy, it will be discussed with the Institution's Continuing Education Committee, continuing this research. The project was approved by the Research Ethics Committee of the institution of origin of the researchers, according to protocol n \ 2011, and later appreciated by the Hospital Superintendence where the study was developed. RESULTS From January first to June 30 th, 2011, 218 notifications of adverse events characterized as errors or near misses in the medication process were referred to the Patient Safety Committee of the host institution. However, four referred to errors in capillary glycemia prescription and were excluded. Thus, the study sample consisted of 214 reports. The analysis of these sheets comprised the phase of observation of reality. Of the evaluated notifications, 204 (95.3%) were characterized as errors and ten (4.7%) were almost mistakes in the medication process, being that they were predominantly filled in the morning shift (50.5%) and Nurses (47.2%) (Table 1). J Nurs UFPE on line., Recife, 11(Suppl. 5): , May.,

4 Table 1. Distribution of notifications according to the shift and the professional that made the notification. Ribeirão Preto, São Paulo, Brazil, Variables n % Notification time Breakfast in the morning (07h01 to 13h00) Evening afternoon (1:13 a.m. to 7 p.m.) Evening party (7:01 a.m. to 7:00 p.m.) Professional who made the notification Nurse Pharmaceutical Administrative officer Nursing assistant Doctor Information not available As to the place where the event occurred, 96 (44.9%) were in Unit I and 118 (55.1%) in Unit II. Of the total number of events, 34.6% occurred in Unit I, but, without specifying the clinic. The Psychiatry Unit (n = 32, 15%), followed by the unit specialized in the treatment of infectious diseases (n = 14, 6.5%), hospitalization unit of the surgical clinic (n = 13, %) and pediatric hospitalization unit (n = 10, 4.7%), all belonging to Unit II. Other clinics of Unit II that were notified: surgical block, central chemotherapy, epilepsy surgery center, adult and pediatric intensive care centers, private clinic, medical clinic, dermatology, pharmacy, neurology, postoperative recovery room of surgery Thoracic unit, immune-intervention unit and renal transplantation unit. The other reporting clinics of Unit II were: adult intensive care center, medical clinic, pharmacy, pediatrics, clinical stabilization room, emergency room and unit of infectious infantile diseases. Regarding the patients involved in reports of errors and almost errors in the medication process, 112 (52.3%) were males. The mean age was 42.8 and the median was 47 years (minimum of seven days of life and maximum of 88 years). It is noteworthy that 14 subjects (6.5%) were children under one year of age, but, the highest concentration of patients occurred in the age group of years (n = 40, 18.7%),. One of the mandatory items in completing the notification refers to the occurrence of harm to the patient as a result of adverse events. In 186 reports (86.9%), it was reported that no damages occurred; in 21 situations (9.8%), the patient was kept under observation, and in seven cases (3.3%), the patient was reported to have suffered damage. Although in the computerized system there is currently no item to specify the type of damage that the patient suffered, it was possible to identify, from the available information, that in none of these cases the damage was severe, not resulting in sequelae or prolongation of hospitalization. In 47.7% of the cases, notifications were made to the electronic system on the same day of the event. The median was between one and two days. In only one case, did the notifier take 62 days to make the notification, but, the reason could not be identified. Adverse events were, mostly, errors (n = 204, 95.3%), occurred at the morning shift (n = 106, 49.4%) and were classified as prescription errors (n = 164, 76.6% ) (Table 2). J Nurs UFPE on line., Recife, 11(Suppl. 5): , May.,

5 Table 2. Distribution of adverse events according to type, classification, shift and professional involved. Ribeirão Preto, São Paulo, Brazil, Variables n % Type of adverse event Error Almost error Event Classification Prescription Management Register Dispensing Preparation Request Event Hours Breakfast in the morning (07h01 to 13h00) Evening afternoon (1:13 a.m. to 7 p.m.) Evening party (7:01 a.m. to 7:00 p.m.) Professional involved Doctor Auxiliary or Nursing technician DPA employee * Nurse Not reported J Nurs UFPE on line., Recife, 11(Suppl. 5): , May., ,3 4,7 76,6 17,3 2,8 2,3 0,5 0,5 49,4 26,7 23,9 76,6 13,5 6,1 0,5 3,3 * DPA - division of pharmaceutical assistance, but it was not possible to identify the professional category In addition to the 37 adverse events classified as administration errors, another eight errors identified in the prescription (3.75%) resulted in administration errors. In 12 of the 164 notifications of prescription errors, this information could not be identified. Among the adverse events that occurred, 26 different situations were identified; in 105 (49.1%) were related to errors in the prescribed dosage of medication; in 23 (10.7%), the product / medication was wrong in 15 situations (7%), the medication was prescribed without indication and in 12 reports (5.6%), the error was related to the route of administration of the drug. Other examples of situations identified were: wrong patient, wrong time, unmanaged medication, presentation of medication prescribed or incorrectly entered, delayed dispensing, medication prescribed duplicity, among others. Among the 164 adverse events related to prescription, in 95, problems were identified in the dosage of prescribed drugs. As for the 37 errors occurred at the time of administration of the medicines, in nine situations the wrong drug was administered, and in six situations, the correct medication, but, in the wrong dosage. The classification of the event allowed the identification of the key points: Medical Prescription and Medication Administration. At the time of the notification, the notifier must also assign what he or she considers to be the cause of the occurrence of the adverse event, with a total of 26 different causes being reported. In 58 reports (27.1%), the cause was not reported; in 60 cases (28%), the notifier attributed the occurrence of the error to the inattention; 41 (19.2%), to the lack of knowledge about the drug; in 12 (5.6%) situations, the events occurred because the prescription was repeated without analyzing the actual need for maintenance of the prescribed items. Other causes attributed to the errors were the fact that the registration of the medication in the system was wrong (2.8%); the doctor did not know the computerized system (2.3%); the professionals were overworked (1.9%), among others. The main cause related by the notifiers to the errors identified in the prescriptions was inattention (41 cases), followed by lack of knowledge about the medicine (38 cases). Inattention was also considered as the main cause of errors at the time of drug administration (19 cases). In view of the severity related to the occurrence of errors in the medication process, it is expected that the professional will take some kind of action against the identification of the same. Among the immediate actions reported by the notifiers, in 66 cases (30.8%) the physician was notified; in 50 cases (23.4%), the physician was informed and the prescription was reviewed. For 32 times (15%), the error was identified at the pharmacy and, therefore, the medication was not dispensed. Nursing staff orientation was done in only 11 cases (5.1%). Other actions taken were communication to the nurse responsible for the shift, correction of

6 the drug registration by the pharmaceutical assistance division, monitoring of the patient, among others less frequent. When observed the type of product involved in the event, in 37 notifications (17.3%), this information was not registered. Among the available ones, 101 different types of sera or drugs belonging to the various classes, as vasoactive amines, analgesics, antiemetics, anticoagulants, anxiolytics, antimicrobials, antipsychotics, bronchodilators, corticosteroids, diuretics, hypoglycemic agents, chemotherapeutic agents, sedatives, among others were identified. The most frequently reported medications were vancomycin hydrochloride (2.8%), potassium chloride 19.1% (2.8%), quetiapine (2.8%), fentanyl (1.9%) and nicotine patch (1.9%). DISCUSSION According to the data presented, one can carry out the theorizing phase described below. It is observed that medication errors can occur in the most diverse hospital units and reach patients in all age groups. Although Unit I has a smaller number of beds, it proportionally presented a higher incidence of errors in the medication process, which may be related to the severity of the patients attended at this location. In this context it is necessary to consider that the occurrence of medication errors varies according to the hospital sector, and areas with high demands of patients with greater severity and clinical complexity, such as emergency and intensive care units, are more subject to occurrences Of these events. 13 The fact that most of the reports have been performed in the morning, this is probably due to the routine of the institution, since the prescriptions of patients already hospitalized are made during this period, when professionals perform activities such as requisition and dispensation Of prescribed drugs, and end up identifying the errors. Still, the nurse, although it may not be the professional who identified the mistake, for having the role of supervisor in the team, ends up being communicated by the other members and makes the notification. In this study, errors in prescription were responsible for the highest number of reports (76.6%), followed by administration errors (17.3%), a situation found in a recent study carried out in an intensive care unit 14 and also in a study carried out in Mid-1990s (15), showing that this problem has persisted over the years. These findings corroborate with data found in the literature, where it is observed that almost half of medication errors occurred in Japan (66%) and the USA (49%) occurred in the prescription phase, followed by the medication administration phase. 14 It is known that medical prescription consists of the first stage of the drug use cycle and plays an important role not only in prevention but also in the occurrence of errors, since this is the reference document that guides and influences the other stages of the drug process. Administration of drugs One of the measures proposed in the literature as a way of solving this problem would be the implementation of computerized prescription. 16 In this sense, many advances in the technological area have been occurring in the last decades, in order to improve this practice more and more, offering greater ease and Safety for professionals, and, especially, providing minimal injury to patients. In the service studied, the prescriptions are electronic and, therefore, there are medication errors, a situation that reinforces that the fact that prescription is electronic does not revoke the possibility of medication errors, since, still in this format, the use of acronyms, abbreviations and erasures, facilitating confusion in the reading of information by the health team 17. Therefore, it is necessary, in addition to electronic prescription, to institute measures to sensitize prescribers about the importance of a clear, complete and accurate prescription so that safety can be printed in the cycle of medication use in the hospital environment. 16 The final stages of the medication process are attributions of the Nursing team. These professionals end up being the last to have the opportunity to avoid medication error 18. According to the World Health Organization, 85% of prescribing errors are recognized by the professional, thus preventing the occurrence of adverse events. These statements corroborate with the findings of this study, in which the nurse was the professional who most reported the occurrence of errors. 2 Most of the errors were identified and these did not cause harm to patients, however, these possible errors pose a risk to patient safety. Thus, in this phase of theorization, it was possible to identify in the literature strategies that aim to reduce the occurrence of errors in the phases of drug preparation and administration. One of them refers to the observation and use of the right eight, being: medication, patient, dose, route of administration, time, infusion time, J Nurs UFPE on line., Recife, 11(Suppl. 5): , May.,

7 medication validity and approach. In order to optimize this strategy, some measures must be taken, which also encompass previous stages of the medication process. The following stand out: the identification of patients by bracelets containing their names in legible letters; questioning the patient with his full name and checking the identification of the bed; preventing patients with similar names from occupying the same ward, implementing computerized prescription; dispensing unit dose; use of bar codes; medical prescription with appointment, containing schedule, route, clear written dose and time of infusion, being with the medical prescription in the act of the preparation must be with the medical prescription, and carry out double checking during handling and administration of the medication. 19 Nursing has a great responsibility in the administration of medication, but, a study that evaluated the knowledge of Nursing assistants about medication considered it unsatisfactory, a result that constitutes a significant risk for medication errors. The importance of the role of the nurse in the medication process for a safe treatment was emphasized, and it is necessary that these professionals have adequate knowledge and skill during the dispensing and administration of medications. 20 Thus, another strategy to deal with occurrence of errors and their prevention would be the guidance and education of the professional. However, in less than half of the 38 errors that involved Nursing professionals this approach was used. In most cases, the first initiative was only the communication to the doctor on call. Although the error is the responsibility of the professional, a well structured system can lead to minimize these errors, as well as prevent them. 21 The institution where the study was developed has already developed some proposals for advancement in this process, such as the electronic prescription system and the bedside design (use of bar code identification) that is being planned. It was also proposed the elaboration of a manual of standardization of maximum dose, minimum dose and dilution of drugs that should be included in electronic prescription software, thus, avoiding, frequent errors in the doses of prescribed drugs, as observed in the presented data. The use of technology has been presented as a way to increase safety at the time of medication administration. A recent study in England showed that the use of a barcode reader to identify both the patient and the medication led to a reduction of 2.89 to 1.48 errors per ten thousand doses administered. 22 Another measure that can be used in the attempt to decrease the occurrence of medication errors is the double check in the administration phase. However, in a systematic review of the literature, sufficient evidence was not found to support or refute this practice, although it may bring benefits. 23 A study conducted at the UK neonatal intensive care unit evaluated the effect of a multifaceted educational intervention on both the incidence, and clinical importance (severity) of medication errors. The intervention consisted of five periods of theoretical activities with an hour of duration each, and they were approached calculation, reconstitution, compatibility, administration rate and aseptic technique in the preparation and administration of medications. The intervention also had 30 minutes of practical activity, performed individually with each nurse in the sector, in addition to a visit to the pharmacy department. From the total number of observations, the incidence of errors decreased from 49% to 31%. However, although there was a reduction, the rates remained alarming. Thus, the authors consider that, although the intervention has significantly reduced the occurrence of errors, other measures need to be taken to improve safety related to the use of drugs. 24 In addition to the above mentioned need for knowledge, other factors should be considered when it comes to preventing errors in the medication process. In this study, the lack of knowledge was attributed to the occurrence of 19.2% of adverse events, while inattention was reported by the notifiers as the cause of 28% of reported errors. This data is in agreement with that presented in a study that reports inattention as one of the possible causes of errors (3). However, it is necessary the commitment of the institution and its leaders in order to identify with their employees what factors may be influencing this lack of attention. These data will be presented to the institution's board of directors to carry out this evaluation. It is important to highlight that this study was developed based only on the reported events, and the numbers presented here may represent only a small portion of the errors that actually occur. This situation may be explained by the lack of appreciation that the Nursing team gives to this type of event because they believe that, most of the time, J Nurs UFPE on line., Recife, 11(Suppl. 5): , May.,

8 they do not cause more serious repercussions for the patients. 1 In addition, health professionals often, relate the same With shame, fear and punishment. When errors occur, there is a tendency to hide them and underreporting masks the problems of medication systems. 3 One way to remedy this barrier would be to make professionals aware that reporting adverse events, whether related to the medication process or not, is not intended to identify and/or punish the professional involved in the error, but rather to identify the problems that have occurred, and mainly, the causes related to these occurrences, so that pertinent measures can be taken. In order to increase the number of notifications, the National Health Surveillance Agency has provided an electronic form so that professionals can notify medication errors anonymously. 25 Another strategy that will be suggested is the maintenance of campaigns that focus on the need for professionals to report errors in the shortest possible time, so that further investigation is initiated if it is deemed necessary. It should be noted that a publicity and campaign work on the importance of these notifications has already been made in the institution, but the maintenance of these is necessary. Also noteworthy is the fact that several units have not reported any errors in the medication process, and it is important to investigate whether this process is actually working effectively or whether the errors are being over-reported. Limitations of the Study It should be noted that this study was based on the electronic notifications filled out by the institution's servers regarding the occurrence of adverse events in the medication process, however, some events may still be underreported. Another point is that neither the number of prescriptions nor the number of drugs prescribed in the period was raised, and it cannot be inferred that the number of notifications made is in line with the data presented in the literature. CONCLUSION The drug administration process is broad and involves several professionals. This study found, as main errors, those related to the prescription of drugs, which, was often, identified early and in few caused harm to the patient. It can also be verified that errors are common to all areas of the institution, requiring a continuous process of training, thus, seeking to improve the quality of care provided and patient safety. Based on the data of this study, suggestions found in the literature, service reality and strategies that have already been analyzed, it is intended to launch proposals for educational actions, together with the Patient Safety Committee of the Institution, that cover the entire multidisciplinary team and contribute To minimize this problem of clinical importance that is present in the health care sectors. REFERENCES Toffoletto MC, Padilha KG. Consequências dos erros de medicação em unidades de terapia intensiva e semi intensiva. Rev Esc Enferm USP [Internet] June [cited 2012 Mar 20];40(2): Available from: df World Healht Organization. WHO patient safety curriculum guide: multi-professional edition, 2011 [Internet]. Geneva: WHO; 2011 [cited 2012 Mar 20]. Available from: _eng.pdf Beccaria LM, Pereira RAM, Contrin LM, Lobo SMA, Trajano DHL. Eventos adversos na assistência de enfermagem em uma unidade de terapia intensiva. Rev Bras Ter Intensiva [Internet] July/Aug [cited 2012 Mar 20];21(3): Available from: n3.pdf Ministério da Saúde (BR), Agência Nacional de Vigilância Sanitária. Resolução RDC nº 45, de 12 de março de Dispõe sobre o Regulamento Técnico de Boas Práticas de Utilização das Soluções Parenterais (SP) em Serviços de Saúde [Internet]. Brasília: Ministério da Saúde; 2003 [cited 2012 Apr 20]. Available from: dc/45_03rdc.htm National Coordinating Council for Medication Error Reporting and Prevention. Taxonomy of medication erros [Internet]. [S.l]: NCC-MERP; 2001 [cited 2012 Mar 20]. Available from: /taxonomy pdf Padilha KG, Secoli SR. Erros na administração de medicamentos. Prat Hosp. 2002;4(19):24-9. (IMPRESSO). Clarck P. Medication errors in family practice, in hospitals and after discharge from the J Nurs UFPE on line., Recife, 11(Suppl. 5): , May.,

9 hospital: an ethical analysis. J Law Med Ethics. 2004;32(2): PMID: Carvalho VT, Cassiani SHB. Erros na medicação e conseqüências para profissionais de enfermagem e clientes: um estudo exploratório. Rev Latino-Am Enfermagem [Internet] [cited 2012 Mar 20];10(4): Available from: pdf Lei nº 7.498, de 25 de junho de 1986 (BR). Dispõe sobre a regulamentação do exercício da enfermagem, e dá outras providências [Internet]. Brasília: Presidência da República; 1986 [cited 2012 Mar 20]. Available from: Silva AEBC, Cassiani SHB. Administração de medicamentos: uma visão sistêmica para o desenvolvimento de medidas preventivas dos erros na medicação. Rev eletrônica Enferm[Internet] [cited 2012 Mar 20];6(2): Available from: /810/926 World Healht Organization. Patient Safety: A World Alliance for Safe Health Care [Internet]. Geneva: WHO; 2004 [cited 2012 Mar 20]. Available from: nce/en/ Berbel NAN. A metodologia da problematização no ensino superior e sua contribuição para o plano práxis. Semina Nov;17:(n.esp.):7-17. (IMPRESSO) Santos AE, Padilha KG. Eventos adversos com medicação em serviços de emergência: condutas profissionais e sentimentos vivenciados por enfermeiros. Rev Bras Enferm [Internet] [cited 2012 Mar 20];58(4): Available from: 58n4.pdf Jennane N, Madani N, OuldErrkhis R, Abidi K, Khoudri I, Belayachi J, et al. Incidence of medication errors in a Moroccan medical intensive care unit. Int Arch Med [Internet] [cited 2012 Mar 20];4:32. Available from: PMC /pdf/ pdf Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, et al. System analisys of adverse drug events. JAMA July;274(1): DOI: /jama Aguiar G, Silva LA, Ferreira MAM. Ilegibilidade e ausência de informação nas prescrições médicas: fatores de risco relacionados a erros de medicação. Revista Bras Prom Saúde [Internet] [cited 2012 Mar 20]:19(2): Available from: Gimenes FRE, Marques TC, Teixeira TCA, Mota MLS, Silva AEBC, Cassiani SHB. Administração de medicamentos, em vias diferentes das prescritas, relacionada à prescrição médica. Rev Latino-Am Enfermagem [Internet] [cited 2012 Mar 20];19(1): Available from: /4283/5440 Telles Filho PCP, Praxedes MFS, Pinheiro MLP. Erros de medicação: análise do conhecimento da equipe de enfermagem de uma instituição hospitalar. Rev Gaúcha Enferm [Internet] Sept [cited 2012 Mar 20];32(3): Available from: f Gimenes FRE, Miasso AI, Lyra Júnior DP, Grou CR. Prescrição eletrônica como fator contribuinte para segurança de pacientes hospitalizados. Pharm Pract [Internet] [cited 2012 Mar 20];4(1):13-7. Available from: _original3.pdf Simonsen BO, Johansson I, Daehlin GK, Osvik LM, Farup PG. Medication knowledge, certainty, and risk of errors in health care: a cross-sectional study. BMC Health Serv Res [Internet] July [cited 2012 Mar 20];11:175. Available from: /articles/ / Miasso AI, Grou CR, Cassiani SHB, Silva AEBC, Fakih FT. Erros de Medicação: tipos, fatores causais e providências tomadas em quatro hospitais brasileiros. Rev Esc Enferm USP [Internet] Dec [cited 2012 Mar 20]:40(4): Available from: 4a10.pdf Richardson B, Bromirski B, Hayden A. Implementing a safe and reliable process for medication administration. Clin Nurse Spec May/June;23(3): DOI: /NUR.0b013e fbe Alsulami Z, Conroy S, Choonara I. Double checking the administration of medicines: what is the evidence? A systematic review. Arch Dis Child Sept;97(9): DOI: /archdischild Chedoe I, Molendijk H, Hospes W, Van Den Heuvel ER, Taxis K. The effect of a multifaceted educational intervention on medication preparation and administration errors in neonatal intensive care. Arch Dis J Nurs UFPE on line., Recife, 11(Suppl. 5): , May.,

10 Fetal Neonatal Ed Nov;97(6):F DOI: /fetalneonatal Ministério da Saúde (BR), Agência Nacional de Vigilância Sanitária. Formulário Erros de Medicamentos [Internet]. Brasília: ANVISA; 2007 [cited 2012 Mar 20]. Available from: rro/index.asp Submission: 2015/09/23 Accepted: 2017/03/23 Publishing: 2017/05/15 Corresponding Address Mayra Gonçalves Menegueti Escola de Enfermagem de Ribeirão Preto Universidade de São Paulo/EERP/USP Av. Bandeirantes, s/n Bairro Monte Alegre - CEP: Ribeirão Preto (SP), Brazil J Nurs UFPE on line., Recife, 11(Suppl. 5): , May.,