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Jun 3, 2018

5th World Congress on Vascular Access

Medication-preparation and administration errors in an oncology hospital: a direct observation study

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medication

intravenous

errors

team

preparation

administration

Abstract

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Abstract

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Keywords

medication

intravenous

errors

team

preparation

administration

Abstract

Introduction: Despite efforts intended to improve patient safety, medication errors persist globally. Errors in preparing and administering medications are caused by healthcare professionals and constitute preventable events that may generate serious patients harm. Intravenous (IV)-associated medication errors are especially dangerous, whereas adverse outcomes can be more severe when compared with other administration’s routes. Objectives: Identify the main errors in the preparation and administration of IV medications made by the nursing staff of an Oncology hospital in Southern Brazil. Methods: An exploratory-descriptive study was conducted at Santa Casa de Misericórdia Hospital in Porto Alegre, Brazil, between February to May 2017. A direct observational technique was used to collect data from nurse medication rounds through a standard observation tool. A nurse observer, member of the Vascular Access and Infusion Therapy Team, followed the nursing staff for the duration of the medication round, watching the preparation and administration of each dose, and recording details of errors that were executed. After the observation, the professional was promptly educated to correct the errors and to emphasize best practices. Results: Six (4%) nurses and 147 (96%) licensed practical nurses were examined during the study. 173 IV medications/solutions were observed. The mistakes made in the preparation of medications were: failure to verify medical prescription (91,2%), e.g., patient’s full name, medication’s name, posology, dose, time of administration; failure to clean the bench before preparing medications (66,5%); failure to disinfect the vial/ampoules before opening (48,2%); use of wrong medication reconstitution (70%) and dilution (39,3%). Regarding the failures related to medication administration, the most frequent were: patient identification was not verified in 93%; failure to disinfect catheter connectors before access (43,4%) and speed of incorrect infusion (85%). Conclusions: Results point to the need for ongoing education of nursing staff and interdisciplinary strategies for preventing IV-associated medication errors.

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© Copyright 2019 Morressier GmbH.
All rights reserved.