Concern about human error and organizational accident risk management is relatively recent.
For at least two decades, several studies in different countries have evaluated the patient safety in hospitals, but more attention is needed to system failures, in order to measure and evaluate what happened to develop strategies capable of increasing and improving the quality of health services.
The combination of the complexity of medical procedures, human interactions and technologies greatly interfere with patient safety.
And it allows for different situations for the Adverse events:
- Lack of staff on the team;
- Lack of adequate equipment to carry out procedures;
- Burnout of the medical team;
- Inexperience of employees;
- Lack of measurement and analysis of Adverse events occurred.
The lack of specific processes to improve these weaknesses allows problems related to patient safety are in most hospitals.
It is necessary to identify the causes of errors and develop initiatives that characterize patients, types of injuries, intentional and unintentional injuries, the probabilities of occurrences and the severity of AEs.
It was published in April 2021, a study regarding the incidence and preventability of Adverse Events in adult patients admitted to a high-complexity Brazilian hospital. This article analyzed medical records of patients hospitalized during 2015.
The article showed that the incidence rate of AEs related to healthcare in hospitalized patients in 2015 was 33,7%, allowing the occurrence of 4,97 AEs per 100 patient-days.
Regarding the severity of AEs, most of them (63,2%) were mild AEs.
Moderate AEs reached 20,7% and serious AEs reached 16,2% of hospitalized patients.
Another important piece of information is that 58,3% of the registered AEs were avoidable.
An example of a preventable AE is medication-related errors.
In any part of the medication process, from medical prescription, separation, preparation, storage, dispensing and administration of medications, they must be constantly monitored so that actions can be defined that ensure the patient safety.
According to the article, the most common errors related to medications are:
- Intravenous solutions, which have a low dosage rate;
- High-alert medications, which often cause serious harm to patients;
- Errors in programming infusion pumps, regarding the correct dosage, patient weight, volume of medication, hours and minutes of treatment;
- The confusion in the similarity between the names of the medicines (lookalikes);
- Lack of information about medicines;
- Biological contamination related to the preparation of medicines;
- The lack of double checking.
In the constant search to reduce and eliminate these errors, in addition to the standardization of processes, the implementation of intelligent systems such as:
- Software to calculate medication dosage, to differentiate the writing of medications Look-a-likes and similar packaging, in addition to providing quick and reliable information on medicines
- And equipment such as infusion pumps and smart cabinets, unitizing machines, repackage and store the medicines.
Furthermore, it is very important to pay attention to, and provide constant and meaningful training to, the professionals who work directly in these processes involving medicines, such as pharmacists and pharmacy technicians, as well as nurses, nursing technicians and assistants.
Adequate and well-supervised care must be provided for all patients around the clock.
