Prevalência de danos causados por erros de medicação envolvendo medicamentos de alta vigilância

• Ano de defesa: 2018
• Autor(a) principal: Sodré-Alves, Bárbara Manuella Cardoso
• Orientador(a): Oliveira Filho, Alfredo Dias de
• Tipo de documento: Dissertação
• Tipo de acesso: Acesso aberto
• Idioma: por
• Programa de Pós-Graduação: Pós-Graduação em Ciências Farmacêuticas
• Palavras-chave em Português: Efeitos colaterais de medicamentos; Medicamentos de alta vigilância; Erros de medicação; Danos; Eventos adversos a medicamentos preveníveis; Hospitais; Prevalência
• Palavras-chave em Inglês: High-alert medication; Medication error; Harm; Preventable adverse drug events; Hospitals; Prevalence
• Área do conhecimento CNPq: CIENCIAS BIOLOGICAS::FARMACOLOGIA
• Link de acesso: http://ri.ufs.br/jspui/handle/riufs/8959

INTRODUCTION: Although patient safety institutions define High-Alert Medications (MAVs) as those that are at increased risk of causing significant harm to patients as a result of a failure to use, there are few scientific studies to prove the prevalence of harm due to MAVs. OBJECTIVES: To determine the prevalence of harm to patients involving MAVs due to medications errors (MEs) in hospitals. Make recommendations for conducting studies that identify harm caused by MEs and for the preparation of lists of MAVs. METHODOLOGY: Chapter 1 was carried out through a systematic review of the PubMed, Scopus, Web of Science and Lilacs databases, considering the studies published until April 2017, using descriptors and their synonyms in different combinations. Then, titles, abstracts and full texts were evaluated by two authors independently, according to the previously established inclusion criteria. In case of discrepancies, a third evaluator was consulted. The articles were included when they determined or allowed the determination of the rates of harm caused by MAVs as a result of MEs in hospitals. Chapter 2 comprised recommendations for patient safety from the studies found in chapter one. RESULTS: In the systematic review, five articles met the inclusion criteria. The overall prevalence of harm resulting from MEs involving MAVs was 16.3%. Less than 0.01% of MEs involving MAVs resulted in death. Hypotension, hypoglycemia, hyperglycemia, hemorrhage, cardiac arrest, stroke, prolonged hospitalization, coma, permanent injury, death have been reported. The drugs most related to the damages were 15% potassium chloride, insulin, anticoagulants, epoprostenol, anesthetics. The recommendations proposed in chapter two include methods for conducting studies that identify MEs harm and emphasize the importance of hospital units to create their own lists of MAVs. CONCLUSION: Two-thirds of the medications on the ISMP list of MEs from the United States and Brazil did not provide evidence of potential harm. In general, few studies - characterized by methodological and conceptual heterogeneity - were performed to determine the prevalence of harm resulting from errors involving these drugs.