COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDY

• Autor(a) principal: Paulino,Gabriela Machado Ezaias
• Data de Publicação: 2021
• Outros Autores: Matsuda,Laura Misue, Matta,Alessandra Cristina Gobbi, Ferreira,Andressa Martins Dias, Dias,Alexsandro de Oliveira, Silva,Luiz Fernando da
• Tipo de documento: Artigo
• Idioma: eng
• Título da fonte: Texto & contexto enfermagem (Online)
• Texto Completo: http://old.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072021000100337
• topic: Patient safety; Accident due to falls; Medication error; Medical errors; Cost and cost analysis; Root cause analysis

ABSTRACT Objectives to characterize accidents/falls and medication errors in the care process in a teaching hospital and to determine their root causes and variable direct costs. Method cross-sectional study implemented in two stages: the first, was based on the analysis of secondary sources (notifications, medical records and cost reports) and the second, on the application of root-cause analysis for incidents with moderate/severe harm. The study was carried out in a teaching hospital in Paraná, which exclusively serves the Brazilian Unified Health System and composes the Network of Sentinel Hospitals. Thirty reports of accidents/falls and 37 reports of medication errors were investigated. Descriptive statistical analysis and the methodology proposed by The Joint Commission International were applied. Results among the accidents/falls, 33.3% occurred in the emergency room; 40.0% were related to the bed, in similar proportions in the morning and night periods; 51.4% of medication errors occurred in the hospitalization unit, the majority in the night time (32.4%), with an emphasis on dose omissions (27.0%) and dispensing errors (21.6%). Most incidents did not cause additional harm or cost. The average cost was R$ 158.55 for the management of falls. Additional costs for medication errors ranged from R$ 31.16 to R$ 21,534.61. The contributing factors and root causes of the incidents were mainly related to the team, the professional and the execution of care. Conclusion accidents/falls and medication errors presented a low frequency of harm to the patient, but impacted costs to the hospital. Regarding root causes, aspects of the health work process related to direct patient care were highlighted.