Strategies to prevent risk-generating conditions related to drug administration: a scope review
DOI:
https://doi.org/10.17267/2317-3378rec.2022.e4592Keywords:
Nursing Care, Patient Safety, Administration, Intravenous, Intensive Care UnitsAbstract
OBJECTIVE: To map safety strategies in the literature to prevent risk-generating conditions related to intravenous drug administration in critically ill patients. METHODS AND MATERIALS: This is a scoping review, following the methodology of the Joanna Briggs Institute (JBI), of studies published between 2012 and 2021, without language limitations or study design, with a search in the online databases SciELO, Medline/PubMed, LILACS, BVS and BDENF. RESULTS: 261 records were found, of which 11 were included in this review, identifying 8 strategies for preventing risk-generating conditions during intravenous drug administration. CONCLUSION: Possible strategies to be implemented in practice were listed, enabling the mitigation of errors in intravenous drug administration and increasing safety in infusion therapy in intensive units.
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(1) Ministério da Saúde (Brazil). Agência Nacional de Vigilância Sanitária. Plano Integrado para a Gestão Sanitária da Segurança do Paciente em Serviços de Saúde: Monitoramento e Investigação de Eventos Adversos e Avaliação de Práticas de Segurança do Paciente [Internet]. Brasília: Ministério da Saúde; 2015. Available from: https://proqualis.net/relatorio/plano-integrado-para-gest%C3%A3o-sanit%C3%A1ria-da-seguran%C3%A7a-do-paciente-em-servi%C3%A7os-de-sa%C3%BAde
(2) Organização Mundial da Saúde (WHO). Medication Without Harm - Global Patient Safety Challenge on Medication Safety [Internet]. WHO; 2017. Available from: https://www.who.int/initiatives/medication-without-harm
(3) Gelsdorf L, Gaedke MA, Koepp J. Segurança do paciente na administração da antibioticoterapia em UTI Adulto: Reconhecendo as condições geradoras de risco. Rev Enferm At In Derme. 2021;95(33):e-21026. https://doi.org/10.31011/reaid-2021-v.95-n.33-art.964
(4) Gonçalves LA, Andolhe R, Oliveira EMD, Barbosa RL, Faro ACM, Gallotti RMD, et al.Nursing allocation and adverse events/incidents in intensive care units. Rev. Esc. Enferm. USP. 2012;46(SPE):71-77. https://doi.org/10.1590/S0080-62342012000700011
(5) Melo ABR. Enfermagem e segurança na terapia medicamentosa em unidades intensivas [dissertation] [Internet]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2007. [cited 2022 nov. 23]. Available from: https://www.bdtd.uerj.br:8443/bitstream/1/11315/1/Anna%20Bianca%20Ribeiro%20Melo.pdf
(6) Toffoletto MC, Padilha KG. Consequences of medical errors in intensive and semi-intensive care units. Rev. Esc. Enferm. USP. 2006;40(2):247-252. https://doi.org/10.1590/S0080-62342006000200013
(7) Novaretti MCZ, Santos EDV, Quitério LM, Daud-Gallotti RM. Nursing workload and occurrence of incidents and adverse events in ICU patients. Rev Bras Enferm. 2014;67(5):692-699. https://doi.org/10.1590/0034-7167.2014670504
(8) Arboit EL, Camponogara S, Magnago TBS, Urbanetto JS, Beck CLC, Silva LAA. Factors contributing to the incident occurrence of security related to drug use in intensive care. Rev Pesq Cuid Fund. 2020;12:1030-1036. https://doi.org/10.9789/2175-5361.rpcfo.v12.7456
(9) Camerini FG, Silva TGP, Costa BDS. Estratégias para reduzir condições geradoras de riscos relacionados a administração medicamentosa: um protocolo de revisão de escopo. 2022. https://doi.org/10.17605/OSF.IO/68JNH
(10) Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372(71). https://doi.org/10.1136/bmj.n71
(11) Hebbar KB, Colman N, Williams L, Pina J, Davis L, Bost JE, et al. A Quality Initiative: A System-Wide Reduction in Serious Medication Events Through Targeted Simulation Training. Simul Healthc. 2018;13(5):324-330. https://doi.org/10.1097/SIH.0000000000000321
(12) Bastos C, Barbieri MC. Administration of intravenous medication in hospitals. Millenium. 2020;2(11):49-55. https://doi.org/10.29352/mill0211.05.00260
(13) Kang MJ, Jin Y, Jin T, Lee SM. Automated Medication Error Risk Assessment System (Auto-MERAS). J Nurs Care Qual. 2017;33(1):86-93. https://doi.org/10.1097/NCQ.0000000000000266
(14) Farzi S, Irajpour A, Saghaei M, Ravaghi H. Causes of Medication Errors in Intensive Care Units from the Perspective of Healthcare Professionals. J Res Pharm Prac. 2017;6(3): 158-165. https://doi.org/10.4103/jrpp.JRPP_17_47
(15) Berdot S, Vilfaillot A, Bezie Y, Perrin G, Berge M, Corny J, et al. Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial. BMC Nurs. 2021;20(153):1-11. https://doi.org/10.1186/s12912-021-00671-7
(16) Silva EF, Faveri F, Lorenzini L. Erro de medicação no exercício da enfermagem: uma revisão integrativa. Enferm Glob [Internet]. 2014;13(2):330-345. Available from: https://scielo.isciii.es/pdf/eg/v13n34/pt_revision1.pdf
(17) Strudwick G, Reisdorfer E, Warnock C, Kalia K, Sulkers H, Clark C, et al. Factors Associated With Barcode Medication Administration Technology That Contribute to Patient Safety: An Integrative Review. Jour Nurs Car Qual. 2018;33(1):79-85. https://doi.org/10.1097/NCQ.0000000000000270
(18) Pena MM, Braga AT, Meireles ES, Vassao LGC, Melleiro MM. Mapping of medication errors at a university hospital. Rev. Enferm UERJ. 2016;24(3):e7025. https://doi.org/10.12957/reuerj.2016.7095
(19) Santos LL, Camerini FG, Fassarella CS, Almeida LF, Setta DXB, Radighieri AR. Medication time out as a strategy for patient safety: reducing medication errors. Rev Bras Enferm. 2021;74(1):e20200136. https://doi.org/10.1590/0034-7167-2020-0136
(20) Magalhães AMM, Moura GMSS, Pasin SS, Funcke LB, Pardal BM, Kreling A. The medication process, workload and patient safety in inpatient units. Rev Esc Enferm USP. 2015;49(spe):43-50. https://doi.org/10.1590/S0080-623420150000700007
(21) Figueiredo TWB, Silva LAA, Brusamarello T, Oliveira ES, Santos T, Pontes L. Tipos, causas e estratégias de intervenção frente a erros de medicação: uma revisão integrativa. Rev Enferm Atenç Saúd. 2018;7(2):155-175. https://doi.org/10.18554/reas.v7i2.2494
(22) Kaushal R, Bates DW. Information technology and medication safety: what is the benefit?BMJ Qual Saf. 2002;11(3):261-265. http://dx.doi.org/10.1136/qhc.11.3.261
(23) Bates DW, Cohen M, Leape LL, Overhage JM, Shabot MM, Sheridan T. Reducing the frequency of errors in medicine using information technology. Journ Ame Medic Inform Assoc. 2001;8(4):299-308. https://doi.org/10.1136/jamia.2001.0080299
(24) Abbasinazari M, Zareh-Toranposhti S, Hassani A, Sistanizad M, Azizian H, Panahi Y. The effect of information provision on reduction of errors in intravenous drug preparation and administration by nurses in ICU and surgical wards. Acta Med Iran [Internet]. 2012;50(11):771-777. Available from: https://acta.tums.ac.ir/index.php/acta/article/view/3991
(25) Reeves S. Why we need interprofessional education to improve the delivery of safe and effective care. Interf. 2016;20(56):185-196. https://doi.org/10.1590/1807-57622014.0092
(26) Tromp M, Natsch S, van Achterberg T. The preparation and administration of intravenous drugs before and after protocol implementation. Pharm world scienc. 2009;31(3):413-420. https://doi.org/10.1007/s11096-008-9269-5
(27) Instituto Brasileiro Para Segurança do Paciente. Como usar o método SBAR na transição do cuidado [Internet]. 2019. Available from: https://segurancadopaciente.com.br/qualidade-assist/como-usar-o-metodo-sbar-na-transicao-do-cuidado/
(28) Needleman J, Buerhaus P, Pankratz S, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med. 2011;364(11):1037-45. https://doi.org/10.1056/NEJMsa1001025
(29) Teixeira TCA, Cassiani SHB. Root cause analysis: evaluation of medication errors at a university hospital. Rev Esc Enferm USP.2010;44(1):139-146. https://doi.org/10.1590/S0080-62342010000100020
(30) Santana BS, Rodrigues BS, Stival MM, Rehem TCMSB, Lima LR, Grou Volpe CR. Interrupções no trabalho da enfermagem como fator de risco para erros de medicação. Avanc Enferm. 2019;37(1):56-64. http://dx.doi.org/10.15446/av.enferm.v37n1.71178
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Copyright (c) 2022 Flavia Giron Camerini, Thays Geovana Pacheco da Silva, Danielle de Mendonça Henrique, Camilla Garcia de França Gonçalves, Beatriz Diniz dos Santos Costa, Cintia Silva Fassarella
This work is licensed under a Creative Commons Attribution 4.0 International License.
This work is licensed under a Creative Commons Attribution 4.0 International License.
