• Elena Bohomol, Lais Helena Ramos, and Maria D'Innocenzo.
• Nursing and Health Services Evaluation Studies and Research Group, São Paulo Federal University, São Paulo, Brazil. ebohomol@uol.com.br
• J Adv Nurs. 2009 Jun 1;65(6):1259-67.

AimThis paper is a report of a study to investigating the incidence types and causes of medication errors (MEs) and the consequences for patients. Background. Medication errors are a common problem in hospitals around the world, including those in Brazil.MethodAn exploratory, quantitative survey design was used and 44 adult inpatients were studied over a 30-day period in 2006. Three different methods were employed: anonymous self-reports, staff interviews and review of patient prescriptions.FindingsA total of 305 MEs was observed. The mean (sd) number was 6.9 (6.8) per patient. The numbers of MEs per day differed statistically significantly between the two groups with length of stay in the intensive care unit of <1 week and more than 1 week, respectively, with mean (sd) of 0.4 (0.38) vs. 0.73 (0.39) The most frequent types were: omission (71.1%), wrong time of administration (11.5%), and prescribing errors (4.6%). The main causes were: medication not available in the hospital (41%); pharmacy stocking and delivery problems (16.3%); transcription errors (11%). No death was directly related to any ME.ConclusionThere is a need to develop a culture of safety and quality in patient care. An understanding of the profile of ME types and frequencies in an institution is fundamental to raise awareness and implement measures to avoid them. Structural and procedural changes in hospital organization, with a focus on the efficacy, efficiency, and effectiveness of the medication system are needed to reduce MEs.

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