看護とケアのジャーナル

Mapping the Medication System: Weaknesses and Risk Management

Abstract

Cris Renata Grou Volpe*, Diana Lucia Moura Pinho, Marina Morato Stival Lima, Walterlânia Silva Santos, Tania Cristina Santa Barbara Rehen and Silvana S Funghetto

Secure systems aimed at preventing medication error are the essential. Our objective was to describe and map the medication system of a large hospital in Brasilia, DF, Brazil and propose risk management strategies for their principal weaknesses. For this cross-sectional, exploratory, and descriptive study, the data was collected with the support of two nurses trained by the researcher. Direct observations and semi-structured interviews of professionals involved in the medication system covered the processes: prescription, dispensing, preparation, and administration of medications. The data collection period was from May 8 to 22, 2012. Eight nursing technicians from this study site, who are responsible for the preparation and administration of medications, participated in the study. We identified 34 activities, undertaken by different professionals, which show the complexity and greater possibility of error. The weaknesses identified include interruptions, displacement, environmental problems, human resources, lack of patient identification, infrastructure, technical problems during preparation and administration, as well as deficiencies in compliance with rules and security protocols. It was concluded that the more the process is computerized the less weaknesses are present. Therefore, implementation of risk management strategies and the use of technologies are needed to detect and reduce risks to ensure the quality of the executed processes.