In opposition to this recommendation, this study noted that 63.9% of the study subjects indicated that they did not participate in courses or conferences on drug preparation and administration in the last year and that most have doubts regarding the action of the drugs, doubts that they resolve with their colleagues and not with the consulting nurse. Consequently, it is suggested that, to provide safe and quality care, it is necessary that work processes be reviewed based on scientific evidence and that professionals are trained and properly qualified, both leaders and those who carry out their orders. Educational strategies, mediated by focus groups or educational websites and didactic simulation games, have proven to be important interventions to reduce drug-related incident rates.
The main medication error mentioned by the professionals who participated in the study was that related to doses, which corroborates a study conducted in the United States with 120 patients in which it was shown that half of them were exposed to medication errors, and that most of the errors were linked to the dose. It should be noted that the main factor contributing to dose error in this study is the complexity and specificity of drug therapy in neonatology and pediatrics. In the medical literature, there is evidence of a high prevalence of errors in medical prescription, more prevalent in drugs that want weight-based dosing and, therefore, it is necessary to develop a specific prescription instrument for pediatrics and neonatology, in addition to influencing the agreement of the measures taken when errors have been detected.
In relation to the reasons that contribute to medication error, environmental factors, such as poor lighting and inadequate physical conditions, constitute the highest percentage of the sample, followed by communication problems, which is corroborated by other studies. It is verified that medication errors are due to the lack of preparation and knowledge of professionals, to the overload and stress generated in the work environment and to communication problems between the multidisciplinary team. It is also emphasized that it is common to suspend the administration of drugs and that the doctor who stopped it did not inform the nursing team. The Food and Drug Administration (FDA) evaluated reports of fatal drug errors and found that 16% of the causes of such errors were attributed to communication problems. Consequently, prescribing is an important link in written communication between health professionals, and is seen as the beginning of a series of events within the medication process, which will lead to the safe administration of a dose to the patient.
Effective communication is another important factor in promoting patient safety in drug delivery, present in all interpersonal relationships, and is directly linked as a cause or contributing factor to most incidents. Adequate communication between professionals and patients and/or caregivers in relation to drug administration provided relevant and effective results, thus avoiding the occurrence of new incidents.
In relation to the incidence of errors, it is important to note that, from the recognition of an error, it is necessary to analyze the entire process and the components of the medication system, which can contribute or act as a barrier to overcome the error. These errors can be attributed to professionals, system failures, the institution or even the presentation of drugs. This analysis is indispensable to understand all the factors involved in the medication process, without attributing the failures to the incompetence or irresponsibility of employees. (1t)
In relation to the behavior of the professional in the face of error, most of the interviewees indicated that they notified the nursing coordination area, a fact that diverges from other studies. In a survey conducted in South Florida, it was found that 57.9% would not report an error if they thought it was not dangerous and 25% would not report it for fear of the consequences. The perception of the nursing staff regarding medication errors is that only 45.6% are reported; The rest is omitted for fear of reaction from leaders and colleagues. The treatment given to error notifications with emphasis on staff performance contributes to the non-reporting of all errors, since professionals are afraid to respond to legal and administrative processes, to be labeled as negligent, to lose the trust of the administrator and his teams. It is a worrying reality that must be reversed because not reporting all errors prevents analyzing them and developing possible measures that minimize their frequency and guarantee patient safety.
Studies that problematize the cultural change in the approach to incidents related to patient safety have shown that an intervention specifically focused on this issue for professionals significantly reduces medication errors. In addition, political change in institutions is needed.
One of the main problems identified by the participants of this research was the interruption during the preparation of the drugs, which is included in the research as a critical point that leaves professionals more vulnerable to making a mistake, because they are exposed to distractions. In a study conducted with pediatric nurses, it was shown that the result was negative in 88.9% of the observed interruptions. Consequently, one study suggests that it is necessary to create restricted areas to prepare drugs, and thus avoid interference.
Double-checking is an effective method of eliminating errors in drug delivery. In this study, the nursing team reported that this practice is scarce or practically nonexistent. In addition, there were cases where the drugs were administered by another person and cases where the drugs were not checked against the prescription before administration, which runs counter to good practice recommendations related to drug administration.
In this study, professionals reported that they follow some of the recommended actions in the safe drug delivery process. However, it should be considered that all practices involving patient safety in the health care process, and not just some, must be adhered to. Ensuring that good practices are adhered to prevents barriers from collapsing to prevent injuries.
The results presented are directly related to institutional specificities, a fact that limits generalization. Therefore, the relevance of studies with representative samples is highlighted, with the same theme as that of this study, resulting from the scarcity of studies with such design and focus in pediatrics and neonatology.
