RESUMO
OBJECTIVE: To identify and describe actual or potential medication errors related to drug information inquiries made by staff members of a teaching hospital to a Drug Information Centre from January 2012 to December 2013. METHODS: Data were collected from the records of inquiries made by health care professionals to the Drug Information Centre throughout this period. RESULTS: During the study period, the Drug Information Centre received 3,500 inquiries. Of these, 114 inquiries had medication errors. Most errors were related to prescribing, preparation, and administration and were classified according to severity as category B (57%) (potential errors) and categories C (26.3%) and D (15.8%) (actual errors that did not result in harm to the patient). Error causes included overdose (13.2%), wrong route of administration (11.4%), inadequate drug storage (11.4%), and wrong dosage form (8.8%). The drugs most frequently involved in errors were vitamin K (4.4%), vancomycin (3.5%), and meropenem (3.5%). CONCLUSION: In this study, it was not possible to measure the reduction in error rate involving medication use because of the lack of previous data on this process in the institution. However, our findings indicate that the Drug Information Centre may be used as a strategy to seek improvements in processes involving medication use.
RESUMO
Introdução: Farmacovigilância é definida como o conjunto de atividades relativas à detecção, avaliação, compreensão e prevenção de efeitos adversos ou queixas técnicas dos medicamentos. Objetivo: Descrever as notificações espontâneas de produtos com suspeita de desvios de qualidade, recebidas pela farmacovigilância do Hospital de Clínicas de Porto Alegre no período de 2008 a 2012. Método: Realizado estudo descritivo com dados recebidos pela farmacovigilância e Serviço de Parecer Técnico da instituição, tendo como variáveis: notificadores, produtos, desvios de qualidade, presença de erros de medicação e medidas adotadas após avaliação do produto. Resultados: No período, foram recebidas 191 notificações espontâneas de produtos com suspeita de desvio de qualidade, sendo os funcionários da farmácia (48,7%) e a enfermagem (35,1%) os responsáveis pelo maior número de notificações.Das notificações, em 12,6% foram identificados erros de medicação, 60,2% foram encaminhas para avaliação da indústria e 13% receberam parecer desfavorável para uso na instituição. Conclusão: É fundamental que os profissionais de saúde façam a notificação dos problemas detectados para que se mantenha ou melhore a qualidade e segurança dos produtos.
Background: Pharmacovigilance is defined as a set of activities related to detection, assessment, understanding, and prevention of adverse effects and drug-related technical complaints. Aims: To describe spontaneous reports about products with suspected quality defects filed at the Pharmacovigilance Department of Hospital de Clínicas de Porto Alegre between 2008 and 2012.Method: Descriptive study with data from the Pharmacovigilance Department and Technical Expert Service of the hospital including the following variables: author of the report, products, quality defects, medication errors, measures adopted after product assessment. Results: In the period assessed, there were 191 spontaneous reports of products with suspected quality defects. Pharmacists and nurses accounted for most reports (48.7 and 35.1%, respectively). Of all reports, 12.6% described medication errors, 60.2% were forwarded to the pharmaceutical industry for assessment, and 13% resulted in drugs not being recommended for use at the hospital. Conclusion: Consistent reporting of drug-related problems by health professionals is extremely important to maintain and improve product quality and safety.