COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDY
Autor(a) principal: | |
---|---|
Data de Publicação: | 2021 |
Outros Autores: | , , , , |
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 |
Resumo: | 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. |
id |
UFSC-17_5fcbf1925195a0bad15ad0e9799b1402 |
---|---|
oai_identifier_str |
oai:scielo:S0104-07072021000100337 |
network_acronym_str |
UFSC-17 |
network_name_str |
Texto & contexto enfermagem (Online) |
repository_id_str |
|
spelling |
COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDYPatient safetyAccident due to fallsMedication errorMedical errorsCost and cost analysisRoot cause analysisABSTRACT 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.Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem2021-01-01info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersiontext/htmlhttp://old.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072021000100337Texto & Contexto - Enfermagem v.30 2021reponame:Texto & contexto enfermagem (Online)instname:Universidade Federal de Santa Catarina (UFSC)instacron:UFSC10.1590/1980-265x-tce-2020-0045info:eu-repo/semantics/openAccessPaulino,Gabriela Machado EzaiasMatsuda,Laura MisueMatta,Alessandra Cristina GobbiFerreira,Andressa Martins DiasDias,Alexsandro de OliveiraSilva,Luiz Fernando daeng2021-06-02T00:00:00Zoai:scielo:S0104-07072021000100337Revistahttp://www.scielo.br/tcePUBhttps://old.scielo.br/oai/scielo-oai.phptextoecontexto@nfr.ufsc.br1980-265X0104-0707opendoar:2021-06-02T00:00Texto & contexto enfermagem (Online) - Universidade Federal de Santa Catarina (UFSC)false |
dc.title.none.fl_str_mv |
COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDY |
title |
COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDY |
spellingShingle |
COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDY Paulino,Gabriela Machado Ezaias Patient safety Accident due to falls Medication error Medical errors Cost and cost analysis Root cause analysis |
title_short |
COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDY |
title_full |
COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDY |
title_fullStr |
COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDY |
title_full_unstemmed |
COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDY |
title_sort |
COSTS AND ROOT CAUSES OF MEDICATION ERRORS AND FALLS IN A TEACHING HOSPITAL: CROSS-SECTIONAL STUDY |
author |
Paulino,Gabriela Machado Ezaias |
author_facet |
Paulino,Gabriela Machado Ezaias Matsuda,Laura Misue Matta,Alessandra Cristina Gobbi Ferreira,Andressa Martins Dias Dias,Alexsandro de Oliveira Silva,Luiz Fernando da |
author_role |
author |
author2 |
Matsuda,Laura Misue Matta,Alessandra Cristina Gobbi Ferreira,Andressa Martins Dias Dias,Alexsandro de Oliveira Silva,Luiz Fernando da |
author2_role |
author author author author author |
dc.contributor.author.fl_str_mv |
Paulino,Gabriela Machado Ezaias Matsuda,Laura Misue Matta,Alessandra Cristina Gobbi Ferreira,Andressa Martins Dias Dias,Alexsandro de Oliveira Silva,Luiz Fernando da |
dc.subject.por.fl_str_mv |
Patient safety Accident due to falls Medication error Medical errors Cost and cost analysis Root cause analysis |
topic |
Patient safety Accident due to falls Medication error Medical errors Cost and cost analysis Root cause analysis |
description |
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. |
publishDate |
2021 |
dc.date.none.fl_str_mv |
2021-01-01 |
dc.type.driver.fl_str_mv |
info:eu-repo/semantics/article |
dc.type.status.fl_str_mv |
info:eu-repo/semantics/publishedVersion |
format |
article |
status_str |
publishedVersion |
dc.identifier.uri.fl_str_mv |
http://old.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072021000100337 |
url |
http://old.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072021000100337 |
dc.language.iso.fl_str_mv |
eng |
language |
eng |
dc.relation.none.fl_str_mv |
10.1590/1980-265x-tce-2020-0045 |
dc.rights.driver.fl_str_mv |
info:eu-repo/semantics/openAccess |
eu_rights_str_mv |
openAccess |
dc.format.none.fl_str_mv |
text/html |
dc.publisher.none.fl_str_mv |
Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem |
publisher.none.fl_str_mv |
Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem |
dc.source.none.fl_str_mv |
Texto & Contexto - Enfermagem v.30 2021 reponame:Texto & contexto enfermagem (Online) instname:Universidade Federal de Santa Catarina (UFSC) instacron:UFSC |
instname_str |
Universidade Federal de Santa Catarina (UFSC) |
instacron_str |
UFSC |
institution |
UFSC |
reponame_str |
Texto & contexto enfermagem (Online) |
collection |
Texto & contexto enfermagem (Online) |
repository.name.fl_str_mv |
Texto & contexto enfermagem (Online) - Universidade Federal de Santa Catarina (UFSC) |
repository.mail.fl_str_mv |
textoecontexto@nfr.ufsc.br |
_version_ |
1750118396378218496 |