Dissertations / Theses on the topic 'Medication Systems, Hospital'

Este estudo identificou, analisou e comparou os erros de medicação ocorridos nos processos de preparo e administração de medicamentos, em uma unidade de internação clínica de um hospital público de ensino, pertencente à Rede de Hospitais-Sentinela da Agência Nacional de Vigilância Sanitária (ANVISA) e localizado na cidade de Rio Branco-AC. Trata-se de um estudo observacional e transversal, realizado no período de julho a setembro de 2005. A amostra foi constituída de 1.129 doses de medicamentos. Esta investigação foi desenvolvida em duas fases: na primeira, os dados foram obtidos a partir da observação direta dos processos que compõem o sistema de medicação e de entrevistas com três profissionais: o responsável pelo setor de farmácia, o chefe do serviço médico e a supervisora do serviço de enfermagem. Na segunda fase, foram observados o preparo e a administração de 1.129 doses, e os erros de medicação foram identificados. Os resultados permitiram identificar 404 (35,8%) erros de medicação e um sistema de medicação com 56 ações. Verificou-se que 866 (76,7%) prescrições estavam manuscritas; 126 (11,2%) não continham o nome legível do medicamento; em 267 (23,6%) faltavam as doses; em 107 (9,5%) não constava a via; em 712 (63,1%) não havia a forma de apresentação; em 20 (1,8%) faltava a freqüência; e em 338 (29,9%) não constavam o tipo e volume do diluente para o preparo. No preparo de medicamentos, foi identificado que 976 (86,4%) doses estavam rotuladas incorretamente e 49 (4,3%) doses não possuíam rótulo. Em relação à administração, observou-se que apenas 31 (2,7%) doses foram administradas após conferência direta da prescrição; em 691 (61,2%) doses não ocorreu identificação do paciente e em 904 (80,1%) doses não houve orientação a respeito do medicamento. Constatouse que 179 (78,2%) doses infundidas não foram controladas, e 214 (18,9%) doses foram registradas imediatamente após a administração. Nas observações em que se desconhecia previamente a prescrição do medicamento, ocorreram os seguintes erros: 47 (4,2%) erros de dose, 2 (0,2%) erros de via, 130 (11,5%) erros de horário, 2 (0,2%) erros de pacientes, 11(1%) erros de medicamentos não autorizados e 71 (6,3%) erros de omissão. Nas observações em que se conhecia previamente a prescrição, identificaram-se 17 (1,5%) erros de dose, 85 (7,5%) erros de horário, 4 (0,4%) erros de medicamentos não autorizados e 35 (3,1%) erros de omissão. Nessa etapa, não ocorreram erros de via e de paciente. Propõe-se como medidas para a redução dos erros nessa instituição: formar um grupo multiprofissional com a finalidade de discutir e estabelecer estratégias que possam promover a segurança do paciente; elaborar protocolos de preparo e administração de medicamentos e promover a educação continuada e permanente para os profissionais. Sugere-se, ainda, que a instituição padronize a prescrição médica, normatizando os itens da prescrição dos medicamentos; desenvolvendo um sistema de distribuição de dose unitária e implementando a prescrição médica eletrônica.
This study identified, analyzed and compared the medication errors that occurred in the medication preparation and administration processes at a clinical hospitalization unit of a public teaching hospital, which is part of the Sentinel Hospital Network of the Brazilian National Health Surveillance Agency (ANVISA) and located in Rio Branco-AC, Brazil. We carried out an observational and cross-sectional study between July and September 2005. The sample consisted of 1,129 medication doses. This study was developed in two phases: in the first, data were obtained through direct observation of the medication system processes and interviews with three professionals: the pharmacy sector responsible, the medical service head and the nursing service supervisor. In the second phase, we observed the preparation and administration of 1,129 doses and identified medication errors. The results revealed 404 (35.8%) medication errors and a medication system that consisted of 56 actions. We found 866 (76.7%) handwritten prescriptions; 126 (11.2%) did not contain the readable name of the drug; doses were missing in 267 (23.6%); route in 107 (9.5%); form in 712 (63.1%); frequency in 20 (1.8%); and the diluent type and volume for preparation in 338 (29.9%). In medication preparation, we identified that 976 (86.4%) doses were labeled incorrectly and that 49 (4.3%) doses did not have a label. With respect to administration, only 31 (2.7%) doses were administered after direct verification of the prescription; in 691 (61.2%) doses, the patient was not identified and, in 904 doses (80.1%), no orientation was provided about the drug. We found that 179 (78.2%) infused doses were not controlled, and that 214 (18.9%) were registered immediately after their administration. In those observations when the medication prescription was previously unknown, the following errors occurred: 47 (4.2%) dose errors, 2 (0.2%) route errors, 130 (11.5%) time errors, 2 (0.2%) patient errors, 11(1%) unauthorized medication errors and 71 (6.3%) omission errors. In those cases when the medication prescription was previously known, we identified 17 (1.5%) dose errors, 85 (7.5%) time errors, 4 (0.4%) unauthorized medication errors and 35 (3.1%) omission errors. In this phase, no route and patient errors occurred. To reduce errors at this institution, we propose the following measures: constitute a multiprofessional group to discuss and establish strategies with a view to promoting patient safety; elaborate medication preparation and administration protocols and promote continuing and permanent professional education. We also suggest that the institution should standardize medication prescriptions by normalizing medication prescription items; developing a unit dose distribution system and implementing electronic medical prescriptions.

A administração de medicamentos se constitui num processo multidisciplinar e um multissistema e seus riscos podem ser reduzidos de forma significativa por meio da implantação de processos reconhecidos para melhoria da segurança. Medicamentos Potencialmente Perigosos (MPP) são medicamentos que possuem maior risco de provocar danos significativos aos pacientes. O gerenciamento de risco em saúde é um processo complexo que associa várias áreas do conhecimento e que tem como objetivo prevenir erros e eventos adversos advindos dos procedimentos e produtos utilizados na assistência, em relação aos MPP, é imprescindível implantar barreiras específicas para gerenciar os riscos envolvidos. O objetivo do estudo foi investigar o gerenciamento de risco de MPP em instituições hospitalares. Estudo transversal, quantitativo, não experimental, realizado em quatro unidades de Terapia Intensiva de hospitais gerais, sendo um público, dois privados com fins lucrativos e um privado beneficente. Foi utilizado um instrumento do tipo questionário, com questões fechadas, elaborado pelo pesquisador, validado para face e conteúdo por cinco juízes e quanto a aplicabilidade por meio de um piloto aplicado em uma unidade de terapia intensiva pediátrica. Os participantes foram todos os membros da equipe de enfermagem das unidades de terapia intensiva pesquisadas e todos os farmacêuticos das instituições pesquisadas. Os resultados apontaram que a participação total foi de 76% da população proposta para o estudo. Todos os medicamentos que compunham o instrumento eram considerados como MPP, entretanto, nenhum foi apontado por 100 % dos participantes como MPP, 17 deles foram apontados como utilizados por 95% ou mais dos entrevistados. Desses, o cloreto de potássio, foi o medicamento mais reconhecido como MPP (99%) e o tramadol o menos reconhecido como perigoso (46%). O medicamento apontado como menos utilizado nas unidades pesquisadas foi o hidrato de cloral (14%), reconhecido como MPP por 78%. O medicamento apontado como menos perigoso foi a água estéril em soluções superiores a 100 ml, reconhecida como MPP por 27% dos entrevistados e utilizada por 90%. Itens considerados rotineiros não foram considerados MPP, dentre eles a solução parenteral prolongada, lidocaína, glicose hipertônica de 25 ou 50%, cloreto de sódio e a enoxaparina, considerados como MPP por 61, 61, 69, 72 e 74% dos entrevistados, respectivamente. Os enfermeiros foram os que mais reconheceram a existência de barreiras de prevenção (96%), já os farmacêuticos os que menos reconheceram (78%). Em média, 84% dos profissionais reconheceram a existência de medidas de prevenção na administração de MPP. A barreira mais reconhecida pelos profissionais foi a de acesso restrito aos MPP (79%). Outra barreira foi a verificação dos certos da terapia medicamentosa, que mesmo sendo uma prática recomendada na administração de todos os medicamentos, foi reconhecida somente por 56% dos entrevistados. O reconhecimento dos MPP, assim como as medidas de prevenção de danos relacionados à esta classe de medicamentos ainda é frágil nas instituições de saúde. A adoção de medidas isoladas ou agrupadas de prevenção de riscos não constituem um sistema de gerenciamento de risco institucional, tampouco em relação aos MPP. A constituição dos comitês de segurança do paciente, além de ser uma obrigação legal pode ser um caminho importante para a efetivação do gerenciamento de risco nas instituições. Diante deste contexto, cabe às instituições de ensino melhorar a qualidade da formação profissional em relação à farmacologia, abordando o tema dos MPP, e aos serviços de saúde implementar programas de educação permanente robustos nos ambientes de trabalho, aplicar barreiras de prevenção baseadas em evidencia de forma sistemática e, finalmente, instituir uma política de incentivo à cultura de segurança do paciente por meio de estratégias educativas, estimulando ações não punitivas ao lidar com os erros
The administration of drugs constitutes a multidisciplinary and multi-system process and its risks can be reduced significantly by implementing recognized processes to improve security. High-Alert Medications (HAM) are drugs that bear a heightened risk of causing harm to the patients. The risk management in healthcare is a complex process that associates several areas of knowledge and aims to prevent errors and events that may come from procedures and products used in assistances. Regarding HAM, it is essential to implement specific barriers in order to manage the risks involved. The objective of this study was to investigate the risk management for HAM in hospital institutions. This study is transversal, quantitative, non-experimental and it was performed in four Intensive Care Units from general hospitals, one of them being public, two of them private for-profit, and one of them a charitable hospital. A questionnaire type instrument containing closed questions made by the researcher was used. Its face and content validation were performed by five judges and its applicability validated by a pilot applied in a pediatric intensive care unit. The participants were the entire nursing staff of the researched intensive care units and the entire pharmacists staff of the researched institutions. The results show that the participants were 76% of the proposed populations for the study. All drugs that formed part of the instrument were HAM, however, none of them were pointed out as HAM by 100% of participants and 17 of them were pointed out as being used by at least 95% of the interviewed. Of these, the potassium chloride was the drug that was most recognized as HAM (99%) and the tramadol was the least recognized as being hazardous (46%). The least used drug in the researched units was the chloral hydrate (14%), it was recognized as HAM by 78% of the participants. The drug pointed out as being the least hazardous was the sterile water in solutions superior to 100mL, recognized as HAM by 27% of the interviewed and used by 90% of them. Routine items were not considered HAM; among them, long-term parenteral, lidocaine, hypertonic glucose 25% or 50%, sodium chloride and enoxaparin were considered HAM by 61, 61, 69, 72 and 74% of the interviewed respectively. The nurses were the ones that most recognized the existence of prevention barriers (96%), whereas the pharmacists were the ones that least recognized them (78%). On average, 84% of the professionals recognized the existence of prevention measures in the administration of HAM. The barrier most recognized by the professionals was the restrict access to HAM. Checking the rights of medication administration was another barrier, recognized only by 56% of the interviewed despite the fact that it is recommended when administering all types of drugs. Recognizing HAM as well as the harm prevention measures regarding this type of medicine is still feeble in healthcare institutions. The adoptions of risk prevention measures, isolated or in group, do not constitute an institutional risk management system, let alone regarding HAM. The constitution of patient security committees, besides being a legal obligation, can be an important path to implement risk management in institutions. In face of this, educational institutions need to improve professional training quality in relation to pharmacology, addressing the HAM theme, and, in relation to healthcare services, they need to implement solid permanent educational programs, apply prevention barriers based on systematic evidence and, finally, institute a patient security culture incentive policy through educational strategies, stimulating non-punitive actions when dealing with errors

Limited data exist on the facilitators and barriers to implementing electronic systems for medicines management in hospitals. Whilst numerous studies advocate system use in improved patient safety and efficiency within the health service, their rate of adoption in practice has been slow. The aim of this doctoral research was to explore this under-researched area in three phases. Phase one: - Phase one focused on critically appraising and synthesising the available evidence on healthcare professionals’ perceptions, attitudes, and views of the facilitators and barriers to implementing electronic prescribing, electronic dispensing, and/or electronic administration of medicines in the hospital setting. The review protocol was registered with the Centre for Reviews and Dissemination and conducted according to best practice. Key facilitators included systems improved patient safety and provided better access to patients’ drug records and that team leadership and hardware/software availability and reliability were essential for successful implementation. Key barriers consisted of hardware and network problems, altered work practices, and weakened interpersonal communication between healthcare professionals and with patients. Phase two: - This phase employed a qualitative phenomenological design to gain original insight into the perceptions of local key stakeholders towards the facilitators and barriers to implementing prescribing, robotic pharmacy systems, and automated medication storage and retrieval systems in public hospitals in Ireland using Normalization Process Theory as a theoretical framework. Individual face-to-face semi-structured interviews were conducted in three public hospitals in Ireland with 23 consenting participants: nine nurses; four pharmacists; two pharmacy technicians; six doctors; and two hospital Information Technology managers. Enhanced patient safety and efficiency in healthcare delivery emerged as key facilitators to system implementation, as well as the need to have clinical champions and a multidisciplinary implementation team to promote engagement and cognitive participation. Key barriers included inadequate training and organisational support, and the need for ease and confidence in system use to achieve collective action. Phase three: - A similar qualitative methodology was employed in phase three of this research in order to explore the perceptions of national key stakeholders and eHealth leads towards the facilitators and barriers to system implementation. Sixteen consenting invitees participated: eight hospital leads, four government leads, two regulatory leads, and two academics. Key facilitators included enhanced patient safety, workflow efficiencies, improvements in governance, and financial gains. Perceived barriers included the introduction of new drug errors, loss of patient contact, initial time inefficiencies, and issues with the complexity of integration and standardisation of work processes. Overall, adequate technology, stakeholder involvement, and organisational leadership and support are required at a national and local level to drive the eHealth agenda forward. Testing at scale, contingency plans, and ongoing evaluations will assist in determining success or otherwise of system implementation. This research has generated novel findings with many potentially transferable themes identified which extend the evidence base. This will assist organisations to better plan for implementation of medication-related eHealth systems.

This study examines specific organizational, operational, financial and environmental characteristics to identify factors that are associated with increased likelihood of hospitals' CPOE adoption decision in six rollout regions of the Leapfrog initiatives.Resource dependence theory provides theoretical basis for the study. The study is retrospective observational in design. Individual hospitals are the unit of analysis. The Leapfrog Group's 2002-survey collection serves the primary data source. Univariate statistical methods along with bivariate and ordinal logistic regression models are used to analyze the data. The models provided support for multiple hypotheses for both the adoption and early adoption decisions of study hospitals. The operational characteristics of ownership, in-house physician staff, case mix index and the environmental characteristic of HMO penetration rate had a positive effect on management's adoption decisions. The operational characteristic excess capacity, the organizational characteristic community orientation, the financial characteristic of operating income per admission, and the environmental characteristic of number of HMO contracts had a significant negative effect on CPOE adoption decisions.

Proposta: O hospital é parte integrante de um sistema coordenado de saúde, cuja função é a prestação de serviços. Os administradores hospitalares preocupam-se em obter o menor custo possível e maximizar a qualidade. Como o custo hospitalar tem uma parcela importante representada pelo consumo de materiais e medicamentos, sendo a farmácia o setor responsável pelo controle, estoque e dispensação, o profissional farmacêutico tem-se aprimorado profissionalmente e desenvolvido pesquisas e estudos, para reformular suas atividades básicas e retomar algumas funções primárias como a farmacoeconomia, a fim de adequar-se as novas exigências. É relevante neste contexto o sistema de distribuição de medicamentos, que se iniciou com a dose coletiva, cujos principais problemas era o aumento do potencial de erros de medicação, as perdas econômicas decorrentes da falta de controles, e o tempo excessivo gasto pela enfermagem para separar a medicação, em vez de dar assistência aos pacientes. Depois avançou para dose individualizada, que além de minimizar e/ou extinguir todas as desvantagens da dose coletiva, apresentava um controle mais efetivo do consumo dos medicamentos, aumentando a integração do farmacêutico com a equipe de saúde, sendo sua principal desvantagem, o aumento das necessidades de recursos humanos e infra-estrutura da Farmácia Hospitalar. E por último a dose unitária, originada da dose individualizada, que tem como principais objetivos racionalizar a terapêutica, diminuir custos sem reduzir a qualidade da dispensação; e garantir que os medicamentos prescritos cheguem ao paciente de forma segura e higiênica, assegurando a eficácia do esquema terapêutico prescrito. Após associar os conceitos descritos acima, a farmácia do Centro Cirúrgico do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da USP propôs-se a identificar o elenco representativo de produtos, e utilizar estes grupos de medicamentos, na elaboração, ampliação, e experimentação do sistema de dispensação de kit. Esta nova alternativa pretende atingir como os dois principais benefícios a melhor utilização de recursos econômicos e a elevação da qualidade de assistência prestada ao paciente e equipe multiprofissional. Método: O método de pesquisa utilizado foi um estudo de caso qualitativo/quantitativo, sendo o mesmo realizado no Centro Cirúrgico do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de 12/05/2002 a 22/07/2002. Foram escolhidas como amostra as dez salas do bloco III, onde pudemos acompanhar procedimentos de médio e grande porte de determinadas especialidades médicocirúrgicas. O estudo foi dividido em três etapas, sendo as duas primeiras experimentais, e a terceira apenas de análise e interpretação dos achados. Foi realizado o mapeamento do elenco de medicamentos disponibilizado (seja nos carrinhos de drogas, nos kits e nas solicitações extra) e o levantamento do consumo de três dias de funcionamento de cada sala cirúrgica do Bloco III, nas duas etapas experimentais. Na primeira etapa - pré kit - o levantamento foi realizado através da verificação do elenco e das quantidades contidas nos carros de parada e anestesia de cada uma das salas, às 06h30min da manhã antes do início das cirurgias e no final da tarde após o término da última, assim, delimitando o consumo/dia/sala. Estes levantamentos eram feitos em dias aleatórios para não induzir a equipe médica ou a enfermagem em modificar seu consumo. Na segunda etapa - pós kit - realizou-se o levantamento dentro da unidade farmacêutica através da análise dos documentos de dispensação do kit e notas de débito, onde estavam relacionadas as quantidades de medicamentos utilizadas e solicitadas pela auxiliar de enfermagem durante a cirurgia. A confirmação desta documentação era feita através da conferencia do kit e devolução de medicamentos extra. Os carros de medicamentos não estavam mais sendo utilizados, apenas os kits e os medicamentos extra, que pela rotina estabelecida deviam ser devolvidos após o término de cada cirurgia, não permanecendo nada em sala entre uma cirurgia e outra. Após o fechamento dos dois levantamentos pré e pósimplantação do kit procedeu-se às seguintes análises dos resultados: Comparação do consumo de medicamentos por sala/dia; Relação de preço de cada medicamento utilizado; Cálculo do valor total gasto por sala/dia; Comparação do valor gasto por sala/dia. Vale assinalar que: Os anestésicos inalatórios não entraram no levantamento dos medicamentos utilizados nas cirurgias, pois comportam frações diferentes para cada paciente; No primeiro dia de mapeamento (pré e pós) das salas cirúrgicas, os medicamentos vencidos encontrados foram recolhidos e considerados como consumidos. Resultados: Não houve críticas nem reclamações em relação ao novo sistema implantado. Quantitativamente, houve uma redução de aproximadamente 47% no estoque inicial, 54% nas solicitações extras e 30,4% no consumo de medicamentos, com impacto muito relevante sobre os custos. Conclusões: Foi viável e benéfica a prática de implantação dos kits, pois houve redução de aproximadamente 60% nos gastos, estimados pelo preço de medicamentos, traduzindo menores perdas e desperdícios.
Purpose: The hospital a integrant of a health coordinated system, which duty is offer services. The hospital administrators\' worry is get the lowest cost as possible and increasing the quality. As the hospital cost has an important installment represented by the medicine and materials consumed, and the pharmacy being the control responsible section, storage and dispensation, the pharmacist has improving professionally and developing researches and studies, in order to reformulate ones basics activities and recover some primary functions such as pharmaco economy, in order to adequate the new demands. The medicine distribution system is relevant in this context, which has started with a collective dose, which the main problems were the medicine error increased, the economic losses because of the lack of control, and the excessive expenses by the nurse ring in order to sort out the medicine, instead of patient care. Then it upgrade to the individual dose, which has not only decrease and /or extinguishes all the disadvantage of collective dose, presented a more effective control of the medicine consume, increasing the pharmacist integration along with health group, being the main disadvantage, the increase of Hospital Pharmacy infrastructure and human recourse need. And the one dose being the last one, being a derivation from the individual dose, which has as the main targets rationalize the therapy, decrease the costs without reducing the dispensation quality; and guaranty that the prescribed medicine reach the patient in a hygienic and safe fashion, guarantying the efficacy of the prescribed therapeutic scheme. After having connect the above described concepts, the Surgery Room of Instituto Central do Hospital das Clínicas da Faculdade de Medicina da USP purpose identify a representative product group, and use these medicine group, on the kit dispensation system elaboration, increase , and experiment. This new alternative intend to hit as the two main benefits which are the better use of economic resources and increasing the assistance quality giving to the patient and to the multi professional team. Method: The used research method applied was a qualitative/quantitative study case, where it was applied at the Centro Cirúrgico do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, from 12/05/2002 to 22/07/2002. Were chosen as samples the ten surgey rooms of Block III, where we could follow big and medium port procedures of specific medical surgery specialties. The study was divided into three steps, where the first two experiments, and the third one was only analyses and comprehension of found. From the available medicine group mapping was taken (which means ones in the drug trolleys, at the kits and the extra solicitations) and the inventory of three day consumptions of each surgery room at the Block III, at the two experimental steps. At the first step - pre kit - the inventory was taken through a verification of the group the quantities which were in the drug emergency trolley and anesthesia of each room, at 06:30 min a.m. before the surgeries starting and at the late afternoon after the last surgery happened, so, determining the consumption/ day/room. These inventories were chosen in random days way in order not to prompt the medical or the nursing group to modify their consumption. At the second step - post kit - the inventory was taken in the pharmacy unit through out of a kit dispensation documents analyses and debit note, which were listed the medicine amount used and from the nurse asked for during the surgery. This document confirmation was done through out of the kit checking and the extra medicine return. The medicine trolley were not use any more, only the kits and the extra medicine, which through the established routine should be returned after each surgery ended, and nothing was left in the surgery room between surgeries. The analyses of the results were taken right after the closing of the two research pre and post kit implementation: Medicine consume comparison by room/day; Listing the price of each medicine used; Total expenses calculated by room/day; Comparison of expenses by room/day. Is worthwhile note that: The inhale ting anesthetic are not considered on the used medicine inventory used at the surgery, because it holds different fractions for each patient; At the first surgery room mapping day (pre and post) the out of day medicine were took away and considered as used. Results: There were no criticism nor complaints related to implemented new system. Quantitatively, there was a decrease of 47% on the initial stock, 54% at the extra solicitations and 30,4% at the medicine consumption, with a very related impact on the costs. Conclusions: The implementation of the kits was totally viable because there was about 60% costs reduction, estimated by the medicine price, presenting less losses and wastings.

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This study aimed to identify and describe the factors related to Patient Safety in a medication system according to the nurses analysis in a teaching hospital from the photographic analysis method. This was a cross-sectional, descriptive study with mixed approach in a teaching hospital in Rio Grande do Norte. The population consisted of 42 nurses from inpatient units, of which 34 composed the study sample. As eligibility criteria, we defined nurses from public service and nurses who agreed to participate. Ethical determinations were observed, the study was submitted to the Ethics and Research of the University Hospital Onofre Lopes, obtaining the assent with ethical assessment certificate (CAAE 0098.0.051.294-11). For data collection, we used the photographic method (Photographic Analysis Technique) by Patricia Marck (Canada). It was developed in two phases: at first, we randomly captured photos from the medication system, resulting in 282 images; then we selected/processed the photographs, which were reduced to 10 images in Microsoft Excel 2010; in the second phase, the nurses answered the questionnaire divided into socio-professional profile and Digital Photography Scoring Tool (questions a and b ). For analysis of the question a , we used the content analysis technique, and for b , we used the Statistical Package for the Social Sciences 20.0 (temporary license). The socio-professional profile revealed the predominance of females; age group 34-43 years; professionals with specialization; 10-18 years of length of service; and nurses working exclusively in the hospital and who know the Patient Safety. The photographic analysis in relation to Patient Safety resulted in specific categories for each stage of the medication system. Regarding disposal, we identified Proper verification ; Improper verification ; Correct identification ; Disposal in single doses ; and Improper Environment , with predominance of that last category. As for storage: Proper storage ; Improper storage ; Risk of exchange/disappearance ; and Poor hygiene , with special reference to improper storage. In preparation: Risk of exchanging medication/patient ; Inappropriate physical space ; and Inadequate 9 preparation of controlled drugs , highlighting the first category. In drug administration: Lack of Personal Protective Equipment ; Use of Personal Protective Equipment ; Improper administration technique ; Proper administration technique ; Correct drug identification ; Incorrect drug identification ; and Peripheral venous access without identification . From the safety assessment of 10 photographs, by adapting the scores (1-10) to the Likert Scale, we identified three Totally Unsafe (Level 1), three Unsafe (Level 2), three Partially Safe (Level 3), one Safe (Level 4), and no photograph considered Totally Safe. This study identified the prevalence of unsafety in the medication system in the nurses opinion. We were also able to understand that, although nurses identify safety aspects, the most prevalent categories characterize an unsafe assessment. Nursing needs to reflect on its practice, identifying gaps in the medication system in order to achieve a proper and safe care
O estudo teve como objetivo identificar e descrever os fatores relacionados ? Seguran?a do Paciente em um sistema de medica??o de acordo com a an?lise de enfermeiros de um Hospital de Ensino a partir do m?todo de an?lise fotogr?fica. Tratou-se de um estudo transversal, descritivo, com abordagem mista em um hospital de ensino no Rio Grande do Norte. A popula??o foi composta por 42 enfermeiros das unidades de interna??o, dos quais 34 compuseram a amostra. Como crit?rios de elegibilidade definiu-se enfermeiros servidores p?blicos e que aceitaram participar do estudo. As determina??es ?ticas foram respeitadas, o estudo foi submetido ao Comit? de ?tica e Pesquisa do Hospital Universit?rio Onofre Lopes, obtendo o parecer favor?vel com certificado de aprecia??o ?tica (CAAE n? 0098.0.051.294-11). A coleta dos dados utilizou o m?todo fotogr?fico (T?cnica de An?lise Fotogr?fica) de Patr?cia Marck (Canad?), desenvolvido em duas fases: inicialmente foi realizada captura aleat?ria das fotografias do sistema de medica??o, resultando em 282 imagens; em seguida, realizou-se sele??o/tratamento das fotografias, que foram reduzidas a 10 imagens no Microsoft Excel 2010; na segunda fase, os enfermeiros responderam ao question?rio dividido em perfil s?cioprofissional e Digital Photography Scoring Tool (quest?es a e b ). Para an?lise da quest?o a utilizou-se a t?cnica de an?lise de conte?do e da b o Statistical Package for the Social Scienses-20.0 (licen?a tempor?ria). O perfil s?cioprofissional caracterizou-se pelo predom?nio: do sexo feminino; da faixa et?ria 34-43 anos; de profissionais com especializa??o; do tempo de servi?o de 10 a 18 anos; de enfermeiros que atuam exclusivamente no hospital e que conhecem a Seguran?a do Paciente. A avalia??o da fotografia em rela??o ? Seguran?a do Paciente resultou em categorias espec?ficas para cada etapa do sistema de medica??o. Da dispensa??o, identificou-se: Confer?ncia adequada ; Confer?ncia inadequada ; Identifica??o correta ; Dispensa??o em dose unit?ria e Ambiente impr?prio , com predomin?ncia desta ?ltima categoria. No armazenamento: Armazenamento adequado ; Armazenamento inadequado ; 7 Risco de troca/desaparecimento e Higiene prec?ria , com destaque para o armazenamento inadequado. No preparo: Risco de troca de medicamento/paciente ; Espa?o f?sico inapropriado e Preparo inadequado de medicamentos de uso controlado ; destacando-se a primeira categoria. Na administra??o dos medicamentos: Aus?ncia de Equipamento de Prote??o Individual ; Uso de Equipamento de Prote??o Individual ; T?cnica incorreta de administra??o ; T?cnica correta de administra??o ; Identifica??o correta do medicamento ; Identifica??o incorreta do medicamento e Acesso venoso perif?rico sem identifica??o . Da avalia??o da seguran?a das 10 fotografias, adaptando os escores (1 a 10) ? Escala de Likert, identificou-se: tr?s Totalmente Inseguras (Grau 1), tr?s Inseguras (Grau 2), tr?s Seguras Parcialmente (Grau 3), uma Segura (Grau 4), n?o havendo fotografia considerada Segura Totalmente. Este estudo identificou o predom?nio da inseguran?a no sistema de medica??o na opini?o dos enfermeiros. Ainda, possibilitou compreender que, apesar dos enfermeiros perceberem aspectos seguros, as categorias de maior preval?ncia caracterizam uma avalia??o insegura. A enfermagem precisa refletir acerca da pr?tica, identificando falhas no sistema de medica??o para alcan?ar um cuidado adequado e seguro

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Mestrado Profissional em Ensino na Saúde
Os processos de Educação Permanente surgem para os serviços em geral e seus setores de treinamento ou capacitação com a necessidade da adoção da concepção pedagógica problematizadora, com o propósito de estimular a reflexão da prática e a construção do conhecimento. Nas instituições de saúde não é diferente, porquanto seus trabalhadores cotidianamente precisam também aplicar adequadamente seus conhecimentos à realidade, o que frequentemente ocorre em um cenário complexo, onde a habilidade técnica deve-se aliar à de realizar ações que assegurem a continuidade do processo de trabalho. Nesse contexto, a segurança do paciente internado em um hospital está ligada ao desenvolvimento de algumas ações preventivas, que devem estar baseadas em princípios universais e na realidade específica da unidade de saúde. O gerenciamento do uso seguro de medicamentos é uma prioridade quando se trata de minimizar riscos para o paciente. Nesse cenário, foi delimitado como objetivo principal descrever sobre uma educação permanente fundada na cultura institucional da qualidade, a partir do cotidiano de profissionais envolvidos no processo de medicação do paciente internado; como objetivos secundários: relacionar as principais questões/problemas ligadas ao processo de educação permanente; conhecer possíveis estratégias adotadas pelos profissionais envolvidos com a saúde dos pacientes internados, no enfrentamento de questões ligadas ao processo de medicação e sua efetividade e; identificar estratégias educacionais com potencial de promover a interação/discussão e a solução multiprofissional de questões e problemas ligados ao processo de medicação dos pacientes internados. Metodologia: estudo descritivo de abordagem qualitativa, desenvolvido no Instituto Nacional de Traumatologia e Ortopedia (INTO), instituição pública de saúde, acreditada há seis anos, de referência nacional no atendimento de alta complexidade, localizado no município do Rio de Janeiro. Utilizaram-se como técnicas de coleta de dados: entrevistas em profundidade e grupo focal, em amostra intencional composta por 15 profissionais de saúde. Os dados foram tratados por análise de conteúdo conforme Bardin. Resultados: Da análise dos dados emergiram três categorias, a saber: A Educação Permanente para o compromisso; A Educação Permanente para o convívio e; A Educação Permanente para a mudança. As categorias emergidas mostraram as perspectivas do fenômeno estudado no que compete às dificuldades, ações multiprofissionais para resolução de problemas e para geração da mudança do processo de trabalho no que se relaciona ao processo de medicação do paciente internado. Conclusão: A concepção de Educação Permanente em um serviço de saúde no cumprimento de seu objetivo transformador de ações cotidianas prevê o conhecimento contínuo sobre seus trabalhadores e os aspectos que os tornam participantes do processo na construção de mudanças. A reflexão sobre educação em serviços de saúde dialoga com a que se dá sobre a qualidade da assistência em tais serviços. Assim, o desenvolvimento dos processos de trabalho de uma unidade hospitalar que prima pela qualidade na assistência prestada ao seu cliente, vai além de implementar uma metodologia de gestão que garanta a realização das tarefas conforme os padrões pré-estabelecidos em manuais, rotinas e protocolos.
The processes of Permanent Education for services in general and their training sectors or capacity with the need to adopt the questionable instructional design, in order to stimulate reflection on practice and knowledge construction. In health institutions is no different, because its workers daily need also appropriately apply their knowledge to reality, which often occurs in a complex scenario, where technical skill should be combined with actions to ensure continuity of the work process. In this context, the safety of the patient at hospital is linked to the development of some preventive actions, which must be based on universal principles and the specific reality of the health unit. Manage the safe use of medicines is a priority when it comes to minimizing risks to the patient. Main aim: to describe about one permanent education founded on institutional quality culture, from the everyday lives of professionals involved in medication process of the in-patient. Secondary aims: relate the main issues related to the process of education permanent; know possible strategies adopted by professionals involved with the health of hospitalized patients, in coping of issues related to the medication process and its effectiveness and; identify educational strategies with potential to promote interaction / discussion and multidisciplinary solution of issues and problems related to medication process of inpatients. Methodology: A descriptive qualitative study, developed at the National Institute of Traumatology and Orthopaedics (INTO), public health institution, accredited for six years, national reference in high-complexity care, located in the municipality of Rio de Janeiro. Were used as techniques of data collection: in-depth interviews and focus groups in intentional sample of 15 health professionals. Data were treated by content analysis according to Bardin. Results: Data analysis revealed three categories, namely: Permanent Education for commitment; Permanent Education for socializing and; Permanent Education for change. The categories that emerged showed the prospects of the studied phenomenon related to difficulties, multidisciplinary actions for problem solving and generation change in the working process as it relates to the process of inpatient medication. Conclusion: The concept of Permanent Education in a health service in fulfilling its goal of transforming everyday actions provides the continued knowledge about its employees and the aspects that make them participants in the construction process of change. The reflection about education in health services dialogues with a reflection that occurs about the quality of care in such services. Thus, the development of work processes within a hospital unit that excels in quality of care provided to your customer goes beyond implementing a management methodology that ensures the tasks according to pre-established standards in manuals, routines and protocols.

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Mestrado Acadêmico em Ciências do Cuidado em Saúde
Estudo realizado para obtenção do grau de Mestre em Ciências do Cuidado em Saúde da Universidade Federal Fluminense. Objeto: os processos de medicação realizados pela equipe de enfermagem da Unidade Neonatal do Hospital Universitário Pedro Ernesto. Objetivos: Descrever os processos de preparo e administração de medicamentos, executados pela equipe de enfermagem da unidade, através da construção de fluxogramas; Analisar por meio de incidentes críticos as situações, comportamentos e consequências, positivos e negativos, identificados nos processos de preparo e administração de medicamentos, a partir do relato da equipe de enfermagem. Método: Pesquisa descritiva, qualitativa, utilizando a Técnica do Incidente Crítico (TIC). Para coleta de dados a proposta foi de realização de entrevistas individuais, semiestruturadas com profissionais de enfermagem lotados no cenário do estudo pelo menos desde março de 2012, realizando atividades de assistência direta de enfermagem, sendo esta a amostragem proposital. Foi considerada atingida a saturação dos dados com 39 entrevistas realizadas, sendo 20 com enfermeiros e 19 com técnicos de enfermagem. Para realização das entrevistas contou-se com uma auxiliar de pesquisa. O material foi gravado e posteriormente transcrito. O conteúdo das entrevistas foi lido exaustivamente e pré-analisado nos moldes da TIC tendo como base a separação, nos textos de cada entrevista, dos elementos situação, comportamento e consequência e polaridades positiva e negativa. Por escolha metodológica de unir a análise de conteúdo preconizada por Flanagan àquela descrita por Bardin, os dados foram lançados em quadros, gerando unidades de registro. A seguir foi realizado o agrupamento dos incidentes críticos positivos e negativos em subcategorias, nomeadas por palavras-chave que emergiram dos conteúdos (unidades de significância), Oito categorias foram obtidas, quatro por polaridade: time de medicação, divisão de tarefas, atividades técnicas e atuação da gerência. Leituras das normas e rotinas de medicação da Unidade serviram de base para elaboração de fluxogramas dos processos de trabalho estudados. Como conclusão do estudo foi apresentado que a fluxogramação dos processos indicou a necessidade de reavaliação na divisão de tarefas durante o processos de preparo de medicamentos e necessidade de inclusão de atividades de monitoramento do sistema de medicação. Quanto a análise dos incidentes críticos, as subcategorias de incidentes negativos com mais relatos agrupados foram as denominadas divisão de tarefas e atividades técnicas. Nessas subcategorias os relatos apontaram uma preocupação com a persistência dos erros, com questões éticas e com atividades desenvolvidas em outras fases do sistema de medicação, pontos considerados prioritários nos estudos produzidos na área. Em relação à persistência dos erros, as duas metodologias utilizadas apontam para o mesmo caminho: a necessidade de monitoramento dos eventos adversos e de adoção de estratégias que diminuam a ocorrência e persistência desses eventos. Espera-se que os resultados obtidos e o produto do trabalho possam colaborar com o contínuo desenvolvimento do processo de medicação adotado na Unidade Neonatal, com o desenvolvimento de pesquisas na Instituição e com a melhoria da assistência de enfermagem em geral, já que apresenta metodologias aplicáveis à análise de processos de trabalho em qualquer realidade de cuidado.
This is a research project for the Academic Master’s Degree in the Sciences of Health Care, of the Fluminense Federal University. Object: medication processes executed by the nursing team in the Neonatal Unit of the University Hospital Pedro Ernesto.. Objectives: To describe the process of preparing and administrating the medication, which are performed by the nursing team, byusing flowcharts created to represent this work process. To analyze the situations, behavior and consequences - both positive and negative - identified in the process, based on the reports of the professionals involved. Method: This is a descriptive, qualitative research, using the Critical Incident Technique (CIT) approach. The data was collected through individual, semi-structured, recorded interviews with nursing professionals from the University Hospital. Those workers should be part of the hospital staff at least since march 201, and be involved in activities of direct care, thus being an stratified sample.The data was saturated after interviewing 39 employees: 20 nurses e 19 nurse technicians. A research assistant helped collect the interviews. The data was recorded and later transcribed. The material was then extensively read and preanalyzed following the CIT precepts. ,by separating the following elements: situation, behavior and consequence, and its respective positive and/or negative polarities. It was decided that the methodology of this research would unite the content analysis as it was defined by Flanagan to that of Bardin; this resulted in the creating of data tables from which registration unities were extracted. Afterwards, the positive and negative critical incidents were grouped in subcategories, named after key-words noted from the content of the interviews. Eight categories were obtained, four per polarity: the medication team, task division, implanted technical activities and the actions of the management. The rules and routines of the medication unit served as the base for the elaboration of flowcharts of the studied work processes. The resulting flowchart indicated the need to reevaluate the task division in the process of preparing and administrating the medications, as well as the inclusion of monitoring activities in the medication system. The analysis of the critical incidents showed that the subcategory of negative critical incidents with the most reports were task division and implanted technical activities, in which reports indicated concerns about the persistence of errors, ethical matters and with the activities performed in other stages of the medication process; points that are consistently approached in studies in the field. In relation to error persistence, both of the methodologies applied point out to the same path: the need to monitor the adverse events, and the implementation of strategies to reduce its persistency and occurrences. The author hopes that the results obtained might assist with the continuous development of the medication system adopted by the Neonatal Unit and with the development of researches in the institution, as well as helping improve the nursing assistance in general, since this research works with a methodology which can be applied in the analyzes of work processes in any care-related context.

Os atuais serviços de saúde tornaram-se ambientes complexos e vulneráveis, fazendo-nos repensar acerca da necessidade de simplificar os processos de trabalho de modo a torná-los mais éticos e seguros. Os objetivos do estudo foram analisar o sistema de medicação e os processos de preparo e de administração de medicamentos de uma UTI, à luz da abordagem restaurativa em saúde. Tratou-se de pesquisa multimétodos, com delineamento embutido, a qual aplicou técnicas de coleta de dados embasadas na perspectiva sócio-ecológica: grupos focais, narração fotográfica e foto elicitation. A pesquisa foi realizada em uma UTI de um hospital geral do interior paulista e envolveu a participação de 23 profissionais da enfermagem e um médico intensivista. A investigação ocorreu em quatro fases. Na primeira, grupos focais foram formados com o objetivo de fazer emergir as opiniões dos participantes em relação aos aspectos de segurança, bem como identificar situações no ambiente e nos processos de trabalho que poderiam comprometer a segurança do paciente no preparo e na administração de medicamentos. Na segunda, a pesquisadora, junto à gerente de enfermagem, realizou narrativas visuais com os propósitos de refletir sobre o ambiente assistencial onde os medicamentos são preparados e administrados, de observar condições passadas e de identificar possibilidades de melhorias futuras, no que diz respeito aos aspectos de segurança. Na terceira fase, as imagens foram expostas ao segundo grupo focal com a finalidade de identificar potenciais mudanças a serem implantadas no sistema de medicação, bem como nos processos, nas práticas, nas políticas e no ambiente de trabalho da UTI. Na quarta, novos registros fotográficos foram feitos com o propósito de captar as mudanças ocorridas no sistema de medicação e no ambiente assistencial da UTI, por meio da comparação destes com as fotografias obtidas durante a segunda fase da pesquisa. A coleta e a análise dos dados ocorreram de maneira interativa em todas as fases da investigação, segundo a orientação teórica da abordagem restaurativa em saúde. Os achados auxiliaram na compreensão das barreiras e das medidas facilitadoras voltadas para a segurança no preparo e na administração de medicamentos, a partir da obtenção de seis temas: Identificando o ambiente assistencial como contribuinte para a segurança no preparo e na administração de medicamentos; Identificando riscos no ambiente assistencial; Percebendo o ambiente assistencial como fator de risco para os acidentes ocupacionais; Tendo que conviver com o sentimento de \"impotência\" diante da cultura organizacional vigente; Convivendo com os improvisos no dia-a-dia do trabalho e Vislumbrando possibilidades de mudanças no ambiente assistencial. A partir da construção conjunta do conhecimento entre pesquisadora e pesquisados, os resultados forneceram subsídios para pesquisas futuras e revelaram que os problemas existentes no sistema interferem na segurança, tanto do paciente como do profissional, devendo a instituição rever a forma de gerenciar os riscos existentes no ambiente assistencial.
The current health services have become vulnerable and complex environments. This has made us rethink about the need of simplifying the work processes so that they are more ethical and safer. The goals of the study were the analysis of the medication system and the processes of preparing and administering the medications at an ICU, in the light of the restorative approach in healthcare. It was a multi-method research, with an embedded delineation, which applied collecting techniques of data having a social ecological perspective: focus groups, photo narration and photo elicitation. The research was performed at an ICU of a general hospital in a city in the São Paulo state and it involved the participation of 23 nursing professionals and an intensivist physician. The investigation occurred in four phases. First, focus groups were formed with the goal of getting the participants\' opinions related to the safety aspects to emerge, as well as identifying situations in the work environment and in the processes that could compromise the patient\'s safety in the preparation and in the administration of medications. Next, the researcher, along with the nursing manager, performed several visual narratives with the purpose of reflecting about the healthcare environment where the medications are prepared and administrated, observing past conditions and identifying possibilities of future improvements, when it comes to the safety aspects. After that, the images were exposed to the second focus group with the aim to identify potential changes to be implemented in the medication system, as well as in the processes, in the practices, in the politics and in the workplace environment at the ICU. At the last phase, new photographic registrations were done with the aim to get the changes occurred in the medication system and in the care environment at the ICU, by comparing these ones with the pictures obtained during the second phase of the research. Collecting and analyzing data was performed in an interactive way at all the phases of the investigation, according to the theoretical orientations of the restorative approach in healthcare. The findings helped in understanding the barriers and the facilitating measures directed to the safety in the preparation and administration of medications, after obtaining six themes: Identifying the healthcare environment as a contributor for the safety in the preparation and administration of medications; Identifying risks in the healthcare environment; Realizing the healthcare environment as a risk factor for the occupational accidents; Having to live with an \"impotence\" feeling before the current organizational culture; Living with the everyday workarounds; and Envisioning possible changes in the healthcare environment. From the joint construction of the knowledge among the researcher and the investigated ones, the results provided subsidies for future investigations and revealed that the problems in the system interfere in the safety, both the patient and the professional, having the institution a necessity to revise the way it manages the risks in the healthcare environment.

The overall aim of this thesis was to explore aspects of the subjective views and experiences of doctors as prescribers, focusing on responsibility for and factors of importance in achieving appropriate prescribing. To provide insights into the prescriber’s perspective the study designs were qualitative. In the first studies secondary care doctors’ perceptions of appropriate prescribing and influences in prescribing were investigated in interviews. The doctors perceived that appropriate prescribing needed continuous revision. From the perspective of the prescribers the definition of prescribing could be rephrased as: “the outcome of the recurring processes of decision making that maximises net individual health gains within society’s available resources”. Among the influences in prescribing were guidelines, colleagues and therapeutic traditions. In the subsequent studies the experiences of exchanging information regarding a patient’s drugs in an electronic patient medical record (e-PMR) shared between primary and secondary care and views of responsibility was explored, using focus groups with both primary and secondary care doctors. Considering the gap between health care levels, doctors’ views of responsibility in prescribing and exchange of information are of concern. The doctors expressed how they assume information to be in the e-PMR and active information transfer has decreased. On the other hand, they experienced an information overload in the e-PMR system. There is a need for improved and structured communication between health-care givers. Taking responsibility to review all the patient’s medications was perceived as important, but described as still not done. Lack of responsibility taken was often due to acts of omission, i.e. that doctors did not make needed changes to the list of medications due to different barriers. The barriers rested both with individual doctors and the system, but to ensure solutions that are realisable in practise, perspectives of the doctors need to be taken into consideration when overcoming those barriers.

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Universidade Estadual Paulista (UNESP)
A atenção farmacêutica é uma prática onde o farmacêutico tem a responsabilidade para com o paciente quanto às suas necessidades farmacoterapêuticas, garantindo a eficácia do tratamento e a segurança da farmacoterapia utilizando como instrumento o medicamento. A farmácia hospitalar é um órgão de abrangência assistencial técnico-científico e administrativo onde uma de suas principais funções é estabelecer um sistema racional de distribuição de medicamentos. O objetivo deste estudo foi analisar o sistema de distribuição de medicamentos de uma farmácia hospitalar de um hospital oncológico, bem como identificar os fatores que levam às falhas no processo de distribuição de medicamento. A pesquisa foi realizada na farmácia central de um Hospital Oncológico do Estado de São Paulo em 2007, após aprovação do Comitê de Ética em Pesquisa. A amostra constituiu-se de 3 (12%) farmacêuticos 3 (12%) assistentes de farmácia e 19 (76%) atendentes de farmácia. Todos os profissionais foram consultados quanto a sua disposição para participar do estudo e a seguir, os mesmos assinaram o temo de consentimento livre e esclarecido. Os dados coletados nos mostram que o sistema de distribuição do referido hospital é o sistema por dose individualizada diferenciada, com prescrição eletrônica. Os resultados das observações realizadas durante os 7 dias, indicam o ambiente como principal problema na distribuição de medicamentos (44,77%), pois o local é impróprio, com vários profissionais desenvolvendo atividades diferentes e interrupções freqüentes. Pela observação do ambiente foi possível demonstrar através de fluxogramas todas as ações desenvolvidas pelos profissionais da farmácia desde o momento da chegada da prescrição eletrônica até a entrega dos medicamentos à equipe de enfermagem. As entrevistas...
The pharmaceutical care is a practice where the pharmacist has the responsibility in relation to and with the patient regarding their pharmacotherapeutic needs, guaranteeing the treatment efficiency as well as the pharmacotherapy safety having as its instrument the medicine. The hospital pharmacy is an administrative technical-scientific organ where its main function is to establish a rational system of medicine distribution. The aim of this study was to analyze the medicine distribution system in a hospital pharmacy from an oncologic hospital as well as to identify the factors that lead us to failures related to the medicine distribution process. The survey took place at the central pharmacy from an oncologic hospital in the state of São Paulo after approval of the Committee of the Ethics in Research. The sample includes 3 (12%) pharmacists, 3 (12%) pharmacy assistants and 19 (76%) pharmacy attendants. All the professionals were asked about their willingness to participate in the survey and afterwards they signed on the “Free Will Participation Agreement”. The collected data show us that the distribution system from the above mentioned hospital is the individually differential dose system, with electronic prescription. The results based on the 7 days observation show the environment as the main problem in the medicine distribution (44.77%) once the place is improper and have several professionals performing different activities as well as frequent interruptions. From the environment observation was possible to demonstrate, through the fluxograms, all the actions performed by the pharmacy professionals from the electronic prescription’s arrival until the medicine delivery to the nursing team. The interviews with the professionals show us that the most frequent errors were related to the medicine dispensing (28.05%) and to the medical... (Complete abstract click electronic access below)

Thesis (MSc(Med)(Pharmacy)) -- University of Limpopo, 2010.
SUMMARY Introduction: The Human Immunodeficiency Virus (HIV) pandemic has become a global "monster" and much effort and funds have been channelled by various stake holders to change the deadly course of this threatening disease. Adherence has been identified as a critical element in optimal treatment of the disease with antiretroviral (ARV) medicines. A literature review was conducted on relevant facets of the HI virus, Acquired Immune Deficiency Syndrome (AIDS), disease prevention and treatment with ARVs, treatment obstacles, the importance of a sustained adherence level of at least 95% and the treatment interventions to promote medication adherence. Objectives: The objectives of this study were to evaluate the e-MuM electronic monitoring system (electronic microprocessor, reminder unit [a specialised wristwatch] and software program) for practicality, impact and effectiveness on ARV adherence, to test the ease of use for the patient and pharmacist, to get feedback from patients and clinic staff and finally to make recommendations concerning possible adaptations and the ideal use of the e¬MuM system. Method: The design was a four phase, prospective, randomised experimental, longitudinal study, conducted at the Tshepang Clinic of the Dr George Mukhari Hospital in Garankuwa using 210 volunteer patients.. After signing a consent form, patients were randomized into test and control groups, balanced according to gender and time on treatment. At the end of the baseline phase (only written adherence data collection), both groups were given their stavudine tablets in an electronic monitoring (e-MuM) container (from the end of the second month). The test group received interventions in the form of a alarm watch reminder unit (end of Phase 1), followed by visual (based on e-MuM generated graphs) and verbal feedback (end of Phases 2, 3 and 4). Other adherence tools used to evaluate and compare adherence in this study included a self-assessment questionnaire for gathering quantitative and qualitative data, visual analogue scale (VAS), 2-day and 7-day recall, tablet counts and the biological markers of the patients at the start and end of the study Results: There was no statistically significant difference between demographic data of the two groups at any point during the study. The mean time on treatment of the test group patients increased relative to baseline by the end of the study, which follows a reported trend that patients who have been on treatment for longer, tend to remain in studies. The e-MuM system revealed a large scattering of adherence results in both groups. Medication taken within an hour of the correct time was regarded as "strict" adherence and that taken at any time on the correct day as "lenient" adherence. The most significant increase in mean strict adherence was from Phase 2 to Phase 4 (after two verbal and visual feedback sessions). The adherence increase for the test group was 18.8% and 14.3% for the control group. The mean strict adherence level was 36.1 % for the test group and 29.8% for the control group for the full period. The mean lenient adherence for the full period was 45.5% for the test group and for the control group it was 36.6%. The difference between the two groups in adherence increase over time, did not reach the statistically significant level of P<0.05. One of the difficulties in the study data interpretation of the self-reported adherence was due to patieilts' decanting habits. Patients were asked to state whether and how often they removed their tablets from the original container into another container (decanting). Decanting habit options included daily, weekly, no decanting and unspecified decanting habits. Patients' decanting habits varied greatly. From decanting data available for a total of 209 patients, a majority (145) reported at least two different types of decanting habits for the study period, while five patients reported every decanting habit. Patients statements on their decanting habits were compared with the data recorded by the e-MuM system, but did not correlate at an individual level and were found not reliable enough to permit adjustment of the adherence levels that were calculated by the e-MuM system. Although self-assessment adherence measures exhibited a high degree of correlation, this was in stark contrast with the data obtained from the e-MuM. The mean adherence according to the Visual Analogue Scale (VAS) for the test group and control group was 87.7% and 88.4% respectively. Some of the study participants (11%) marked their adherence out of bounds on the 10cm solid line used for VAS. Despite frequent explanations from staff, some patients were not able to understand the abstract nature of the VAS. This observation may be related to patient educational level, as the majority of study participants (82%) had an incomplete secondary education or lower. In addition, clinic staff and data collectors commented that patients did not want to admit to being non¬ adherent. The mean stated adherence with the 7-day recall was 93.6% for the test group and 92.8% for the control group patients. The 2-day recall was omitted at the end of Phase 2. Adherence measured with tablet counts could not be used as it was only available in 60% of visits by test group patients and 64% of control group patients, as a result of patients not returning their remaining tablets at follow-up visits. Although positive tendencies in biological markers (CD4 and viral load [VL]) were evident towards the end of the study, differences between the groups did not reach statistical significance. The mean increase in CD4 count in the test group over the full period was 76.2 cells/mm3 and the number of patients in the test group with VL < 400 copies/ml increased from 72% to 89%. The mean increase in CD4 count in the control group was 72.2 cells/mm3 and the number of patients with VL < 400 copies/ml increased from 65% to 75%. Conclusion: The results of the study illustrated that the e-MuM system could be integrated in a normal clinic routine but additional staff and facilities (hardware) would be needed. The e-MuM system could be particularly helpful with new or suspected non¬ adherent patients. The disadvantage of the electronic monitoring system is its ability to monitor only one drug per container. It could be used with a fixed combination single tablet regimen. Patients were positive about the reminder unit as a tool to improve adherence. Doctors had mixed opinions of the usefulness of feedback graphs in monitoring adherence. Some patients disagreed with feedback results and this may reflect the anomalies caused by the range of decanting habits. The test group reached higher average rates of adherence than the control group, as jUdged bye-MuM recorded events, but differences were not statistically significant. The e¬ MuM data do not reflect adherence as such, merely container opening patterns, which makes it difficult to interpret results. In focus groups, patients and staff expressed their views about the use of the e-MuM system. No difficulty in the ease of use was reported by patients or staff. Notwithstanding this, a large portion of patients did decant tablets for various reasons, which made calculation of true adherence rates very difficult. A group of patients suggested routine use of the e-MuM system, to keep them conscious of their medication regimen while staff suggested limited use for new patients and non-adherent patients. The size of the container was the biggest obstacle according to patients and clinic staff and a small, more portable container was suggested. The sturdiness of the e-MuM lid with the microprocessor used for the study was questionable. Recommendations: Based on the results of this study, suggestions to increase adherence and utilise the e-MuM system are offered. The ideal medication dosage interval for patients, whose adherence patterns are being monitored electronically, would be once daily. For the e-MuM system to be practical, the device (container with embedded micro chip) has to be small, portable and sturdy. Patients will have to be educated to take every dose directly from the e-MuM container. For optimal e-MuM data interpretation, patient medication taking behaviour, including decanting of tablets must be accurately identified. A trained, dedicated, sensitive person has to interpret data and give feedback to patients.

Orientador: Anselmo Gomes de Oliveira
Banca: Maria Jacira Silva Simões
Banca: Julieta Ueta
Resumo: A atenção farmacêutica é uma prática onde o farmacêutico tem a responsabilidade para com o paciente quanto às suas necessidades farmacoterapêuticas, garantindo a eficácia do tratamento e a segurança da farmacoterapia utilizando como instrumento o medicamento. A farmácia hospitalar é um órgão de abrangência assistencial técnico-científico e administrativo onde uma de suas principais funções é estabelecer um sistema racional de distribuição de medicamentos. O objetivo deste estudo foi analisar o sistema de distribuição de medicamentos de uma farmácia hospitalar de um hospital oncológico, bem como identificar os fatores que levam às falhas no processo de distribuição de medicamento. A pesquisa foi realizada na farmácia central de um Hospital Oncológico do Estado de São Paulo em 2007, após aprovação do Comitê de Ética em Pesquisa. A amostra constituiu-se de 3 (12%) farmacêuticos 3 (12%) assistentes de farmácia e 19 (76%) atendentes de farmácia. Todos os profissionais foram consultados quanto a sua disposição para participar do estudo e a seguir, os mesmos assinaram o temo de consentimento livre e esclarecido. Os dados coletados nos mostram que o sistema de distribuição do referido hospital é o sistema por dose individualizada diferenciada, com prescrição eletrônica. Os resultados das observações realizadas durante os 7 dias, indicam o ambiente como principal problema na distribuição de medicamentos (44,77%), pois o local é impróprio, com vários profissionais desenvolvendo atividades diferentes e interrupções freqüentes. Pela observação do ambiente foi possível demonstrar através de fluxogramas todas as ações desenvolvidas pelos profissionais da farmácia desde o momento da chegada da prescrição eletrônica até a entrega dos medicamentos à equipe de enfermagem. As entrevistas... (Resumo completo, clicar acesso eletrônico abaixo)
Abstract: The pharmaceutical care is a practice where the pharmacist has the responsibility in relation to and with the patient regarding their pharmacotherapeutic needs, guaranteeing the treatment efficiency as well as the pharmacotherapy safety having as its instrument the medicine. The hospital pharmacy is an administrative technical-scientific organ where its main function is to establish a rational system of medicine distribution. The aim of this study was to analyze the medicine distribution system in a hospital pharmacy from an oncologic hospital as well as to identify the factors that lead us to failures related to the medicine distribution process. The survey took place at the central pharmacy from an oncologic hospital in the state of São Paulo after approval of the Committee of the Ethics in Research. The sample includes 3 (12%) pharmacists, 3 (12%) pharmacy assistants and 19 (76%) pharmacy attendants. All the professionals were asked about their willingness to participate in the survey and afterwards they signed on the "Free Will Participation Agreement". The collected data show us that the distribution system from the above mentioned hospital is the individually differential dose system, with electronic prescription. The results based on the 7 days observation show the environment as the main problem in the medicine distribution (44.77%) once the place is improper and have several professionals performing different activities as well as frequent interruptions. From the environment observation was possible to demonstrate, through the fluxograms, all the actions performed by the pharmacy professionals from the electronic prescription's arrival until the medicine delivery to the nursing team. The interviews with the professionals show us that the most frequent errors were related to the medicine dispensing (28.05%) and to the medical... (Complete abstract click electronic access below)
Mestre

Os erros na medicação podem trazer sérias conseqüências aos pacientes, profissionais e às instituições de saúde; resultando de múltiplas causas, dentre elas: falhas profissionais e do sistema de medicação. O objetivo deste estudo foi identificar e analisar os processos do sistema de medicação, suas falhas e propor medidas de melhorias ao hospital. Realizou-se uma pesquisa quantitativa do tipo survey exploratório, na unidade de clínica médica e na farmácia de um hospital geral e universitário do estado de Goiás, após aprovação do Comitê de Ética em Pesquisa. A amostra constituiu-se de um farmacêutico na primeira etapa, 40 profissionais na terceira etapa, sendo 12 (30%) médicos-residentes; 20 (50%) profissionais de enfermagem e 8 (20%) profissionais da equipe de farmácia, além da utilização de 294 prontuários. Realizou-se a coleta dos dados em 2002, por meio de entrevista com o responsável pelo sistema de medicação da instituição; de observação não-participante de ambientes e de ações dos profissionais e acadêmicos; de entrevista com profissionais e de análise de prontuários. Consultaram-se todos os profissionais quanto à sua disposição para participar do estudo e, a seguir, solicitou-se a assinatura do termo de consentimento livre e esclarecido. Os dados obtidos possibilitaram caracterizar os seguintes processos: prescrição de medicamentos realizada manualmente com cópia carbonada, dispensação por dose individualizada, além de indicar que o profissional de enfermagem que administra o medicamento não é o mesmo que o prepara, na clínica médica. Os resultados das observações realizadas durante 21 dias, nos processos de prescrição, dispensação e administração de medicamentos, indicaram: o ambiente como principal problema no processo de prescrição (69%) e de dispensação de medicamentos (30,6%), por se tratar de local impróprio, com ruídos e interrupções freqüentes; falhas na segurança durante a técnica e preparo antecipado do medicamento no processo de preparação (46,8%). O estudo possibilitou, também, a construção de um gráfico do fluxo das 60 ações desenvolvidas desde a prescrição até o monitoramento. As entrevistas com os profissionais apontaram que os tipos de erros mais freqüentes estavam relacionados à prescrição médica (29%) e ao horário (20,6%); suas causas deviam-se a falhas individuais e falta de atenção (47,4%) e excesso de trabalho (14,5%). As falhas individuais dos profissionais foram apontadas também como principal falha do sistema de medicação (27%). A alteração nas atitudes individuais foi a sugestão mais indicada para evitar a ocorrência de erros, com 28,3% das respostas, e a orientação, a providência mais tomada (25%). A análise dos prontuários mostrou prescrições de medicamentos com 64,6% de legibilidade, tendo 62,2% tanto nomes de medicamentos comerciais quanto do princípio ativo; 95% estavam incompletas para algum item; 96% apresentavam abreviaturas e 30% rasuras. Encontraram-se anotações sobre medicamentos apenas em sete relatos de enfermagem e uma outra na evolução médica. A clínica não possui relatório de ocorrências sobre erros na medicação. As medidas propostas para melhorar o sistema e, conseqüentemente, prevenir erros na medicação foram: prescrição eletrônica, dose unitária, relatórios sobre erros, cultura não-punitiva, segurança do paciente e, enfim, simplificação do sistema.
The medication errors can bring serious consequences to patients, professionals and healthcare institutions, they have multiple causes, amongst them failures related to the professionals and related to the medication system. This study’s objective was to identify and to analyse the medication system process, its failures in order to propose improvement actions to the hospital. This exploratory descriptive study took place in the medical clinical unit and in the pharmacy of a general and university hospital of the state of Goiás, after approval of the Committee of the Ethics of the correspondent hospital. The sample included: (first phase) a pharmacist, (third phase) 40 professionals divided into 12 resident physicians (30%), 20 nursing professionals (50%), 8 pharmacy team members (20%); 294 patient charts were also used. The data was collected in 2002 and consisted of an interview with the professional in charge of the medication system, and non-participant observation of the environment and actions of the professionals and the academic people, interviews with the professionals and patient chart analysis. The professionals were asked to sign on the “Free Will Participation Agreement”. It was possible based on the data collected to describe the following processes: handwriting medication prescription using carbon paper, individually dose dispensing and that the nursing professional who administrates the drug is not the same that prepares it in the clinical unit. The results based on the 21 days of observation of the drug prescription, dispensing and administration processes were: the environment is the main problem in the prescription (69%) and dispensing (30,6%) processes, it is a noisy place and interruptions frequently occur; safety failures during the technique and in-advance drug preparation appeared in the top (46,8%) in the preparation process. The data collection also allowed to build a chart of the 60 steps from drug prescription to monitoring. The results from the interviews showed that the most frequent errors were related to both prescription (29%) and schedule (20,6%) and their main cause were individual failures and lack of attention (47,7%) and work overload (14,5%). The individual failures were also listed as the main failure in the medication system (27%). In order to avoid errors 28,3% of the answers suggested to change the individuals’ behavior, and orientation as the administrative action more frequently taken (25%). The patient chart analysis found out the following drug prescriptions characteristics: 64,6% readable, 62,2% using drug brand names as well as the active principle name, 95% incomplete for missing information, 96% using abbreviations and 30% with erasures. Concerning to drug notifications, the analysis also found out 7 nursing reports, one from the physician and that there is no error report in the clinical unit. The suggested improvements to avoid errors and enhance the system are: computerized physician order electronic entry, unit dose, errors reports, non-punitive approach, patient safety, and at last to make the system as simple and lean as possible.

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The practice of prescribing, dispensing and diluting drugs in the hospital organization involves different professionals. For the nursing team it is the preparation and the administration that requires knowledge, attention and responsibility, mainly to avoid the error. The present study aimed to evaluate the possible contributions of the Drug Dilution Unit from the perspective of health professionals and managers. This is a qualitative and quantitative descriptive exploratory study, carried out from June to October 2016, in a medium-sized hospital, including a description of the process of implementation of the Drug Dilution Unit, the experiences, knowledge and needs for the creation of thistechnology. A sample of thirty professionals, composed of nursing technicians, nurses, pharmacists and managers, answered a self-administered questionnaire, structured with 12 closed questions (Likert-scale response) and 12 open questions about dilution unit technology in relation to quality and attention to the medication administration process, nursing care qualification and cost-effectiveness.The average score obtained in relation to patient safety was 14.8 points, reaching the percentage of 77.8% of the expected. The optimization in the medication assistance obtained 15.5 (81.8%), the qualification in the assistance, 14.7 (81.7%) and the cost-effectiveness, 15.8 (87.8%). In the perception of professionals, the unit promoted patient safety, benefited dilution standardization, adequate conference, asepsis of medications and effectiveness in the control, besides the organization and optimization of the time in the work processes, improvement in the qualification of the assistance of Nursing care in relation to patient care, reducing the number of adverse events and drug waste, resulting in a decrease in spending on drugs and materials. The implementation of the dilution unit had an impact on the hospital service with the disruption of the paradigms in relation to the medication assistance, since the change from routine preparation, dilution, to administration, underwent changes to obtain safety in the process. The new service was satisfactory as it stimulated the ability to rethink and seek innovations to transform work routines by qualifying care, medication and professional resources, providing greater patient safety. In view of the results, it can be concluded that the implementation of the Drug Dilution Unit favored the service for the offered advantages, of a technical, therapeutic, care and economic nature.This study allowed: favorable technical opinion of the Regional Nursing Council of Rio Grande do Sul (COREN-RS) and the 4th Regional Health Coordination of Santa Maria-RS; customization of computerized labels for drug identification; and, writing of dilution manual, standardized for the institution that allows to improve the routines of the unit.
A prática de prescrição, dispensação e diluição de medicamentos na organização hospitalar envolve diferentes profissionais. Para a equipe de enfermagem cabe o preparo e a administração que exige conhecimento, atenção e responsabilidade, principalmente para evitar o erro. O presente estudo teve como objetivo avaliar as possíveis contribuições da Unidade de Diluição de Medicamentos na perspectiva de profissionais de saúde e gestores. Trata-se de pesquisa quali-quantitativa descritiva exploratória, realizada no período junho aoutubro de 2016, em hospital de médio porte, incluindo adescrição do processo de implementação da Unidade de Diluição de Medicamentos, as experiências, vivências e as necessidades para a criação desta tecnologia. Uma amostra de trinta profissionais, composta por técnicos de enfermagem, enfermeiros, farmacêuticos e gestores, responderam a um questionário autoaplicável, estruturado com 12 questões fechadas (resposta em escala Likert) e 12 abertas, sobre a tecnologiada unidade de diluição em relação à qualidade e à atenção no processo de administração de medicamentos, à qualificação na assistência de enfermagem e ao custo- efetividade. A pontuação média obtida em relação à segurança do paciente foi de 14,8 pontos, atingindo o percentual de 77,8% do esperado. A otimização na assistência medicamentosa obteve 15,5 (81,8%), a qualificação na assistência, 14,7 (81,7%) e o custo-efetividade, 15,8 (87,8%). Na percepção dos profissionais a unidade promoveu a segurança do paciente, beneficiou a padronização da diluição, a conferência adequada, a assepsia dos medicamentos e a eficácia no controle, além da organização e otimização do tempo nos processos de trabalho, melhoria na qualificação da assistência de enfermagem em relação ao atendimento dos pacientes, reduzindo o número de eventos adversos e desperdícios de medicamentos, resultando em uma diminuição de gastos com medicamentos e materiais. A implementação da unidade de diluição causou impacto no serviço hospitalar com o rompimento dos paradigmas em relação à assistência medicamentosa, pois a mudança da rotina desde o preparo, diluição, até a administração, sofreram mudanças para obter segurança no processo. O novo serviço foi satisfatório, pois estimulou a capacidade de repensar e buscar inovaçõespara transformar rotinas de trabalho qualificando a assistência, medicamentos e os recursos profissionais, proporcionando maior segurança para o paciente. Frente aos resultados pode-se concluir que a implementação da Unidade de Diluição de Medicamentos favoreceu o serviço pelas vantagens propiciadas, de ordem técnica, terapêutica, assistencial e econômica. Este estudo possibilitou: parecer técnico favorável do Conselho Regional de Enfermagem do Rio Grande do Sul (COREN-RS) e da 4a Coordenadoria Regional de Saúde de Santa Maria-RS; customização de etiquetas informatizadas para identificação dos medicamentos; e, redação de manual de diluição,padronizado para a instituição que possibilita aprimorar as rotinas da unidade.

O método da análise de causa raiz tem sido utilizado para investigar e analisar erros de medicação, promover a segurança do paciente e implementar o sistema de forma a garantir a qualidade na assistência e, por isso, ele foi utilizado neste estudo. Os objetivos do estudo foram descrever as doses de medicamentos preparadas e administradas diferentemente daquelas prescritas, em uma clínica médica, de um hospital universitário, utilizando o método da análise de causa raiz; apresentar a freqüência dos tipos de erros identificados, dos turnos de ocorrência, dos profissionais e dos medicamentos envolvidos; elaborar um desenho dos fatores causais de cada dose observada e propor estratégias e recomendações que evitem a recorrência desses erros no sistema de medicação. Tratou-se de estudo descritivo e que realizou uma análise secundária de dados de um estudo já existente. No estudo, 74 erros de medicação foram identificados durante o preparo e a administração de medicamentos pela equipe de enfermagem, sendo que 84,3% foram cometidos por auxiliares de enfermagem que prepararam ou administraram os medicamentos. Erros de dose (24,3%), erros de horário (22,9%) e medicamentos não autorizados (13,5%) foram os mais freqüentes. Dos 70 eventos descritos, a equipe de enfermagem utilizou a requisição da farmácia para preparar os medicamentos em 81,4% das observações, rotulou os medicamentos inadequados ou não rotulou em 80%, não consultou a prescrição médica antes da administração em 74,3% dos eventos, não orientou (41,4%) e não confirmou o paciente pelo nome antes da administração em 22,9% dos eventos. Além desses fatores, outros, como falta de equipamento no setor, medicamento deixado com o acompanhante para administrar, comunicação inadequada e alteração da prescrição médica contribuíram para a ocorrência dos erros. Assim, erros de medicação foram identificados, a análise de causa raiz foi realizada identificando múltiplos fatores que contribuíram para a ocorrência dos erros e estratégias foram recomendadas para evitar a ocorrência dos erros. Este estudo contribuiu para a garantia da segurança do paciente, apresentando o método de análise de erros e as estratégias que podem ser utilizadas pelas instituições para a prevenção dos erros.
Root cause analysis has been used to investigate and analyzing medication errors, promoting patient safety and system improvement, for that, he was used in this study. This study aimed at: describing, by using the root cause analysis method, medication doses prepared and administered differently from those prescribed at a medical clinical of a university hospital; presenting the frequency of the identified error types, shifts of occurrence and professionals and drugs involved; outlining the causative factors for each dose and proposing strategies that will prevent the recurrence of such errors in the medication system. It is a descriptive study in which a secondary analysis of data from a previously existing investigation was performed. In the study, 74 medication errors were identified during medication preparation and administration by the nursing staff, of whose members 84.3% were nursing auxiliaries who prepared or administered medication. Dose errors (24.3%), schedule errors (22.9%) and unauthorized medication (13.5%) were the most frequent. Of the 70 events described, the nursing staff used the pharmacy order to prepare the medication in 81.4% of the observations, labeled inadequate medication or did not in 80%, did not consult the medical order prior to administration in 74.3% of the events, did not provide patient orientation (41.4%) and did not confirm the patient\'s name prior to administration in 22.9% of events. Additionally to these factors, others such as the lack of equipment in the facilities, medication being left for the patient\'s companion to administrate, inadequate communication and alteration of the medical order contributed to error occurrence. Hence, medication errors were identified, and root cause analysis was performed, leading to the identification of multiple factors that contributed to error occurrence, and strategies were recommended in order to prevent it. Therefore, this study has contributed to patient safety by presenting an analysis method and strategies that can be used by institutions for the prevention of errors.

Class of 2013 Abstract
Specific Aims: The objective of this study was to describe the failure rate of activation of medications that employ the ADD-Vantage medication delivery system in one community hospital, Tucson Medical Center (TMC). Methods: A daily, hospital-wide summary was generated identifying all patients currently receiving ADD-Vantage medications using the TMC electronic medical record system, Epic. Data collection occurred on arbitrary days and times from July 2012 to March 2013. Direct observation of a failure or a success in activation occurred by entering a patient’s room after the ADD-Vantage medication was administered by the nurse. Important data collected included: medication, frequency of administration, nursing unit, time of administration, administering nurse, the shift during which the nurse was working and whether or not the medication was or was not properly activated. Main Results: All medications utilizing the ADD-Vantage medication delivery system at TMC were analyzed. The rate of failure across 347 total samples collected on various days and times was 6.92%. Night shift had a higher rate of failure at 11.43% versus 6.41% for day shift (χ2 = 1.23). The General Surgery and Cardiac units of the hospital had the highest rates of failure with 18.18% and 15.38% respectively. Zosyn was improperly activated with greatest frequency with 12 total failures. Conclusion: No statistically significant difference was found between the rates of activation failure for those samples collected during nursing day shift versus night shift. The overall rates of activation failure suggest a significant opportunity for nursing education to improve outcomes.

Introdução - Os medicamentos contribuem de forma significativa para melhorar a qualidade de vida das pessoas, mas não são isentos de riscos. Os erros envolvendo medicamentos têm recebido atenção dos profissionais, das instituições e das autoridades sanitárias no mundo todo. Em hospitais, a farmácia é elo importante no complexo processo de utilização de medicamentos interligando várias ações desenvolvidas em diferentes setores. Sua estrutura física, recursos humanos e tecnológicos e sua organização são fundamentais na prevenção dos erros com medicamentos. Objetivo - Avaliar erros de dispensação de medicamentos em hospital e os fatores envolvidos. Métodos A pesquisa foi realizada em um hospital universitário no Paraná, utilizando-se de três estratégias. 1ª Foram conferidos, de acordo com a prescrição, os medicamentos dispensados pela farmácia para as clínicas médica e cirúrgica no período de 4 a 19 de janeiro de 2010. Os medicamentos analisados eram separados utilizando-se a cópia carbonada da prescrição e dispensados de forma individualizada por paciente ou coletiva, em embalagem plástica (caixas ou sacos), separados por horário de administração, para 24 horas de atendimento. 2 a - Foram entrevistados 19 funcionários da farmácia envolvidos no processo de dispensação sobre erros nesse processo. 3ª Foram avaliados dezenove relatos voluntários de erros de dispensação de medicamentos ocorridos no hospital, entre outubro de 2006 a janeiro de 2010. Resultados Foram analisadas 259 dispensações, 1.963 medicamentos e 4.099 doses. Durante a observação, houve 61 erros de dispensação em 48 prescrições. Os erros ocorreram em 3,2 por cento dos medicamentos e em 1,71 por cento das doses dispensadas. Os erros de dispensação mais freqüentes foram: omissão de medicamento prescrito (23 por cento ); dispensação de medicamento não prescrito (14,8 por cento ); medicamento dispensado na ausência de informação ou contendo informação duvidosa ou ilegível (14,8 por cento ); concentração incorreta (9,8 por cento ); horário incorreto (9,8 por cento ) e medicamento incorreto (6,6 por cento ). Os erros estiveram associados ao número de medicamentos por prescrição e 33 por cento dos erros envolveram medicamentos potencialmente perigosos. Nas entrevistas, foram relatados, como fatores contribuintes para a ocorrência de erros de dispensação, problemas relacionados à comunicação, como: legibilidade da grafia dos prescritores; prescrições ambíguas, incompletas ou confusas e similaridade dos nomes de medicamentos. Em relação às condições de trabalho destacaram-se: pouco tempo para dispensação, sobrecarga de trabalho, nível de ruído, interrupções e distrações. Quanto às questões pessoais, 50 por cento relataram falta de conhecimento sobre medicamentos, estresse e cansaço. Os tipos de erros e os fatores envolvidos foram similares aos de pesquisas semelhantes. Conclusões Os dados sugerem baixa frequencia de erros quando comparados a outros estudos nacionais, o que pode ter ocorrido pela organização do processo de dispensação, dividido em etapas (triagem da prescrição, fracionamento e reembalagem, separação e fechamento das embalagens). A conferência dos medicamentos pela enfermagem e a notificação voluntária mostraram-se importantes na identificação de erros de dispensação. A investigação das circunstâncias de ocorrência dos erros pode oferecer informações importantes para desenvolver estratégias de prevenção
Introduction - Drugs make a significant contribution to improving people\'s quality of life, but are not without risks. Errors involving medications have attracted attention of health professionals, institutions and authorities worldwide. In hospitals, the pharmacy is an important link in the complex drug use process, as it interconnects various actions carried out in different areas. Its physical structure, human and technological resources, and its organization are critical in drug error prevention. Objective - Evaluate drug dispensing errors in hospitals and the factors involved. Methods - The survey was conducted at a university hospital in the state of Paraná, using three strategies. 1 st - The drugs the pharmacies dispensed to the medical clinics and to surgery were compared to the prescriptions in the period ranging from January 4 to 19, 2010. The drugs under analysis were segregated using the carbon copy of the prescription and dispensed individually, per patient, or collectively, in plastic packaging (boxes or bags), separated by time of administration for 24 hours of care. 2 nd - Nineteen employees involved in the pharmacy dispensing process were interviewed concerning errors in this process. 3 rd - Nineteen voluntary reports of medication dispensing errors occurring in the hospital between October 2006 and January 2010 were evaluated. Results - 259 dispensations, 1,963 drugs and 4,099 doses were analyzed. During the observation period, there were 61 dispensing errors in 48 prescriptions. The errors occurred in 3.2 per cent of the drugs and in 1.71 per cent of doses dispensed. The most common dispensing errors were: omission of a prescribed drug (23 per cent ); dispensing of a drug that had not been prescribed (14.8 per cent ); drug dispensed in the absence of information or containing questionable or unreadable information (14.8 per cent ); improper concentration (9.8 per cent ); wrong time (9.8 per cent ); and wrong drug (6.6 per cent ). The errors were associated with the number of drugs per prescription, and 33 per cent of the errors involved potentially dangerous drugs. During the interviews, issues related to communications were reported as contributing factors to dispensing errors and included readability of the prescriber\'s spelling, ambiguous, incomplete, and confusing prescriptions, in addition to drug name similarity. Insofar as working conditions were concerned, the following matters stand out: little time for dispensing, work overload, noise levels, interruptions and distractions. As for personal issues, 50 per cent reported a lack of knowledge about drugs, stress and fatigue. The types of errors and the factors involved were similar to those of similar surveys. Conclusions - The data suggest a low frequency of errors when compared to other national studies, which may have occurred on account of the organization of the dispensing process, divided into steps (screening prescription, fractioning and repackaging, sorting and closing of packages). Drug checking by the nurses and voluntary reporting were important in identifying dispensing errors. The investigation of the circumstances under which errors occurred can provide important information to develop prevention strategies

Thesis (Ph.D. in Clinical Science) -- University of Colorado Denver, 2007.
Typescript. Includes bibliographical references (leaves 86-91). Free to UCD affiliates. Online version available via ProQuest Digital Dissertations;

Magister Public Health - MPH (Public Health)
The prevalence of diabetes in Africa has been on the increase. A prevalence of 1%- 10% has been reported by different authors in different regions in Nigeria. The International Diabetes Federation estimates that 1.9% of Nigerians are diabetic and most of them have complications at the time of diagnosis. Laboratory measurement of Glycosylated hemoglobin (HbA1c) is the method of choice for monitoring glycaemic control but due to its cost and limited availability, most developing countries use fasting plasma glucose (FPG) measurement (which is less reliable) to assess glycaemic control. Most diabetic patients in Nigeria have poor glycaemic control and several factors have been implicated especially socio-economic, behavioral and treatment-related factors. Understanding the reasons for poor glycaemic control is essential in order to reduce the rate of diabetes complications.

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INTRODUÇÃO: Um dos aspectos importantes que frequentemente prejudica a obtenção dos resultados pretendidos com a terapêutica medicamentosa é a não adesão à prescrição médica. Segundo a Organização Mundial de Saúde, os portadores de doenças crônicas são potenciais candidatos ao seguimento inadequado à terapêutica medicamentosa. Estudos relatam que a baixa adesão no Lúpus Eritematoso Sistêmico (LES) pode conduzir à recaídas e potenciais danos ao organismo, aumento da frequência às consultas e admissões hospitalares, conclusões erradas sobre a eficácia da terapêutica e perda de recursos das instituições de saúde. Em países em desenvolvimento existem poucas informações a cerca de quais fatores estariam mais relacionados à adesão no LES. OBJETIVOS: Estimar a prevalência da adesão à terapêutica medicamentosa e analisar associações com as características do regime de tratamento, da doença, das questões demográficas, sociais e econômicas, e dos profissionais e serviços de saúde em pacientes com LES. MATERIAL/MÉTODO: Desenvolveu-se estudo com delineamento transversal em amostra aleatória composta de 246 mulheres com LES atendidas em hospital universitário na cidade do Rio de Janeiro. Os dados foram coletados entre março e agosto/2008, por meio de entrevistas individuais e revisão de prontuários. Utilizaram-se os critérios de Morisk para avaliar a adesão. A análise considerou as variáveis de exposição em três níveis de hierarquia: distal, intermediário e proximal. Na análise bivariada utilizou-se a regressão logística e na multivariada a regressão logística hierarquizada. (...)CONCLUSÃO: Os dados do estudo realizado indicaram que a adesão à terapêutica medicamentosa no LES é um fenômeno complexo e multifatorial. A análise hierarquizada revelou-se uma boa alternativa para avaliar a adesão, pois permitiu visualizar as diversas etapas da análise. A identificação e análise dos fatores que podem levar à não adesão à terapêutica medicamentosa, nos pacientes com LES, permitirão desenvolver ações de saúde pública para reduzir as barreiras no tratamento, assim como os custos assistenciais e, principalmente promover melhor qualidade de vida dos pacientes.
INTRODUCTION: Nonadherence to medication is one of the critical aspects that may very often jeopardize the intended results of treatment based on medical prescriptions. According to the World Health Organization chronic disease patients are potential candidates to inadequate follow up in therapeutic medication. Some studies reported that a low adherence to medication in Systemic Lupus Erythematosus (SLE) may lead to residiva and potential harm to patients, raise the frequency of visits to medical offices and hospital admissions, may lead to wrong conclusions about the efficacy of therapeutics and significant losses of health resources. There are only a few studies in developing countries about intervening factors related to SLE medical adherence. OBJECTIVES: To estimate adherence to medications in Systemic Lupus Erythematosus and analyze associations with characteristics of treatment, with illness, with social, economic and demographic factors and with caracteristics of medical professional and health services in patients of SLE. METHODS: a cross-seccional study was conducted in a random sample of 246 women patients with SLE attending a University Hospital in the city of Rio de Janeiro. Data were collected between March and August 2008 using face-to-face interviews and medical records review. Morisk’s criteria were used to evaluate adherence to medication. The analysis included exposure variables divided into 3 hierarchical levels: distal, intermediate and proximal. The bivariate analysis used logistic regression and multivariate analysis used hierarchized regression model. RESULTS: Demographic and social data showed predominance of black and mestizo women aged 41 ± 12.35 years with completed secondary school, per capita income of 1.27 ± 1.35 average minimum wage. The number of medications in use was 5 ± 2.48, prednisone being the most used. In the interviewed group 31.7% were classified as adherent to medication. Reasons for nonadherence were careless with the time of taking the medications (52.43%), orgetting (38.21%), side effects (13.8%) and stopping the medication when feeling better (7.72%).The multivariate hierarchical regression showed that the factors associated with adherence were: behavior to side effects, hematological changes, mucocutaneous manifestations, legibility of medical prescriptions, education and family support. CONCLUSION: Data from the study indicated that adherence to medication in SLE is a complex, multi-factorial phenomenon. Hierarchized model analysis seemed to be a valuable method to evaluate adherence to medication because it allowed to view the various stages of analysis. Identification and analysis of the various factors that may interfere with adherence to medication in patients with SLE will permit to develop public health actions to reduce barriers in the treatment as well as to reduce health costs and, most important, to improve patients life quality.

INTRODUÇÃO: A terapia antirretroviral (TARV) reduziu a mortalidade e a morbidade por aids, melhorou a qualidade de vida das pessoas vivendo com HIV/aids (PVHA) e, recentemente, foi reconhecida pelo seu papel como instrumento para redução da transmissão do HIV. Entretanto, a efetividade da TARV depende da manutenção de altas taxas de adesão à mesma. Tipo de tratamento, características individuais dos pacientes, barreiras de acesso ao serviço e à informação, falta de regularidade no comparecimento às consultas e às retiradas de medicamentos podem associar-se negativamente à adesão. Do ponto de vista da gestão, a falta à consulta agendada é um problema para os serviços de saúde que pode ser traduzido em custos para a sociedade. O presente estudo tem como objetivo analisar o perfil dos pacientes com HIV/aids que faltaram a consultas médicas agendadas de infectologia em um serviço especializado no atendimento de PVHA adultos, utilizando uma base de dados secundários gerados por um sistema administrativo destinado ao monitoramento da produção e ao faturamento. MÉTODOS: Foram incluídas PVHA em acompanhamento no Serviço de Extensão ao Atendimento de Pacientes HIV/Aids (SEAP HIV/Aids) com registro de pelo menos uma consulta agendada de infectologia em 2006 e 2007. Excluídos os sujeitos com discordância nas informações sobre sexo e data de nascimento, gestantes e com registro de óbito ou de transferência de serviço antes da primeira consulta de infectologia em 2007. Através do Sistema de Informação e Gestão Hospitalar (SIGH) foram obtidos dados do cadastro dos pacientes, registros de consultas e atendimentos em especialidades médicas e disciplinas de saúde, de internações hospitalares no ICHCFMUSP e de retiradas de medicamentos. A variável desfecho foi falta em consulta agendada de infectologia em 2007. As variáveis independentes incluíram características sócio-demográficas dos sujeitos, consultas e atendimentos em especialidades e disciplinas disponíveis no SEAP HIV/Aids, internações no ICHCFMUSP; tipo de médico infectologista que acompanhou o sujeito: se assistente ou residente, mudança de médico e retirada de antirretrovirais (ARV), em 2007. Na análise foram utilizados os testes do qui-quadrado de Pearson e t de Student. RESULTADOS: Sob o olhar da qualidade de informação, observou-se baixa frequência de registros de consultas e atendimentos em duplicidade. Embora a completitude e a acessibilidade tenham sido consideradas adequadas para grande parte dos dados, as variáveis cor, ocupação e endereço, não foram analisadas devido à baixa consistência dos dados referentes às mesmas. Entre os 3075 sujeitos incluídos 38,9% (1195) faltaram em pelo menos uma consulta de infectologia e a taxa de faltas às consultas de infectologia foi de 13,9%; 70,1% (2157) dos sujeitos eram do sexo masculino e não foi observada associação entre sexo e falta em consulta (p=0,32). A proporção de sujeitos que faltaram diminuiu à medida em que aumentou a idade (p<0,001) e a média de idade dos que faltaram foi menor do que a dos que não faltaram (p<0,001). Os sujeitos que faltaram agendaram 33,3% mais consultas em infectologia (p<0,001) e compareceram a menos consultas (p<0,001) quando comparados aos que não faltaram. A falta foi associada a maior comparecimento em consulta sem agendamento (p<0,001) e em atendimento de serviço social (p<0,001), a internação hospitalar no ICHCFMUSP (p<0,001), a assistência feita por médico residente e a troca de médico (p=0,02), e a menor comparecimento em consultas de ginecologia (p<0,001) e de proctologia (p=0,00). Sujeitos em uso de TARV faltaram em menor proporção (p<0,001). A média de retiradas de ARV entre os sujeitos que faltaram foi menor quando comparados aos que não faltaram (p<0,001). A organização do serviço de saúde é um fator relevante para o comparecimento dos pacientes em consulta. No contexto da atenção à saúde de PVHA, acesso a mais modalidades de assistência, atendimento em horário marcado, e uma gestão que tenha por objetivo diminuir as barreiras de acesso ao tratamento podem contribuir para elevar a qualidade da assistência ofertada. A elaboração e acompanhamento de indicadores de qualidade tais como acompanhamento de taxas de faltas e de retiradas de ARV pode contribuir para a redução de taxas de faltas às consultas. Embora ainda necessite de melhorias, o SIGH revelou-se um instrumento útil para a elaboração de indicadores relacionados à qualidade da atenção à saúde de PVHA
BACKGROUND: The highly active antiretroviral therapy (HAART) reduced AIDS morbidity and mortality in HIV/AIDS patients, improved their quality of life and, was recognized as prevention to HIV transmission. However, the success of antiretroviral therapy (ART) depends on high levels of adherence to it. Treatment regimens, patient individual characteristics, access barriers, missing scheduled appointments and not taking ART drugs can be associated with low adherence. For managers, a missed appointment could be translated in costs. Our goal is to characterize HIV/AIDS patients who missed scheduled medical appointments, according to SIGH, an electronic administrative database. METHODS: Adults HIV/AIDS patients followed at a public outpatient clinic specialized in HIV/AIDS attached to the Clinics Hospital of the São Paulo University Medicine School who had at least one scheduled appointment with an infectious disease physician in 2006 and 2007 were included. Patients with uncertain age and gender registry, pregnant or who were transferred or died before first scheduled appointment in 2007 were excluded. The outcome was missed scheduled medical appointment with an infectious diseases physician in 2007. Data on sociodemographic characteristics (age, gender, color/race, occupation, and address), appointments with physicians and health care providers care available in the clinic, hospitalization at Central Institute of Clinics Hospital of the São Paulo University Medicine School and ART withdrawal from the pharmacy in 2007 were obtained from a computerized administrative database; besides, the sort of infectious disease physician (assistant or resident) who cared for the patient, physician changing and number of changes were other independent variables included. Chi-square and Student-t test were used on analysis. RESULTS: We observed few duplicities of registry of appointments. Although the database showed a good completeness and accessibility for most variables, color/race, occupation and address had low consistency and were not analyzed. The study included 3075 subjects, 38.9% (1195) of them missed at least 1 scheduled medical appointment with an infectious disease physician in 2007; 13.9% of all medical appointments were missed. Subjects who missed medical appointments scheduled 33.3% more (p<0.001) and had less medical consultations (p<0.001) compared with those who did not miss medical visits. Seventy one percent (2157) of the subjects were men and we found no association between gender and missing medical appointment (p=0.32). Missing medical appointment was associated with younger age (p<0.001), unscheduled medical (p<0.001) and social worker visits (p<0.001), hospitalization (p<0.001), assistance by resident (p=0.04), change of physician (p=0.02), lower attendance to gynecologist (p<0.001) and proctologist (p=0.00); besides, not be on HAART was associated to missing medical appointment (p<0.001) and subjects who missed medical visits withdrew few ART drugs from the pharmacy (p<0.001). The organization of the health service is relevant for improving patient attendance to it. Access to more medical specialties and health disciplines, scheduled medical visits, reduction of barriers to access are all management instruments to increase the quality of health services. The use of quality indicators, like rate of missed medical appointments and withdrawal of drugs from the pharmacy, may increase the adherence of HIV/aids patients to the treatment. The performance of SIGH was satisfactory when it was used for quality indicators, although some improvement is still necessary

Introdução: A área Hospitalar vem sofrendo constantes mudanças organizacionais devido à introdução de novas tecnologias que incentivam a segurança do paciente. Aquelas aplicadas à distribuição de medicamentos podem abreviar o número de erros de distribuição, obter em tempo real um elevado nível de informação sobre todo processo e gerir melhor o tempo do profissional farmacêutico, de forma a aumentar a intervenção deste na prevenção de erros de medicações e consequentemente, os cuidados farmacêuticos ao doente internado. Objetivos: Avaliar o impacto da implantação de novas tecnologias que visam à maior segurança do paciente em um sistema de distribuição de medicamentos de um hospital universitário. A avaliação foi dividida em: 1) individualização de medicamentos por reembalagem, com o uso de código de barras na identificação dos medicamentos; 2) identificação dos pontos críticos no novo processo estabelecido para o Sistema de Distribuição de Medicamentos por Prescrição Individual; 3) identificação e análise de erros de medicação após implantação de sistema de controle por código de barras. Métodos: Foram realizados estudos de delineamento transversal. Para a avaliação do processo de individualização foi desenvolvido um instrumento de avaliação adaptado de recomendações internacionais e estudos anteriores, segundo as boas práticas de reembalagem. Aplicou-se o instrumento de avaliação na rotina escrita e, por meio da técnica de observação participante, verificou-se a adequação de sua execução, conforme o mesmo instrumento. Para a identificação dos pontos críticos do Sistema de Distribuição de Medicamentos foi analisada cada etapa e verificado onde poderia ocorrer erros de medicação. Para a avaliação do processo de Distribuição de Medicamentos por Prescrição Individualizada foi realizado um estudo transversal, no qual utilizou-se a técnica de observação participante e amostragem por conveniência. Foram avaliadas prescrições médicas vinculadas ao Sistema de Distribuição de Medicamentos por Prescrição Individualizada pela tecnologia do código de barras. Resultados: Para avaliação do processo de individualização foi observado o fracionamento de 42 formas farmacêuticas orais e injetáveis onde a rotina escrita do processo de individualização atendeu a 66% dos itens recomendados e a execução da mesma atendeu a 63%. Para a avaliação do processo de Distribuição de Medicamentos por Prescrição Individualizada foram analisadas 290 prescrições médicas vinculadas ao Sistema de Distribuição de Medicamentos por Prescrição Individualizada, destas, 25% apresentaram algum tipo de erro de medicação. O total de itens analisados foi de 2659, com 74 ocorrências de erros de medicação (2,78%). Comparados com os dados anteriores o número de erros por clínica ou em geral teve uma redução estatisticamente significativa. Conclusões: Os resultados obtidos mostram que a utilização de novas tecnologias aumenta a qualidade do serviço prestado prevenindo erros de medicação. Portanto, o sistema de leitura por códigos de barras, associado a mudanças na infra-estrutura e nos processos de trabalho, podem ser apontados como os principais fatores na diminuição nas taxas de erros de dispensação de medicamentos no hospital estudado.
Introduction: The field hospital has been undergoing constant organizational changes due to the introduction of new technologies that encourage patient safety. Those applied to the distribution of drugs can shorten the number of errors distribution, obtain real-time a high level of information about every process and better manage the time of the pharmacist in order to increase the intervention of the prevention of medication errors. A previous study found problems in the repackaging and an average of about 14% of medication errors in Distribution System for Prescription Drugs traveler at a university hospital. Objectives: To evaluate the impact of deployment of new technologies to the largest patient safety in a system of distribution of drugs in a university hospital. The evaluation was divided into: 1) individualization of medication by repackaging, using bar code identification of drugs, 2) identification of critical points in the new process established for the Distribution System for Prescription Drugs traveler, 3) identification and analysis of medication errors after implementation of control system by bar code. Methods: We performed cross-sectional studies. For the evaluation of the individualization process has been developed an assessment tool adapted from recommendations and previous studies, according to the practice of repackaging. We used the assessment tool in routine writing and, through the technique of participant observation, it was found the suitability of its execution, as the same instrument. For the identification of critical points of the Distribution System of Medicines was analyzed and verified every step which could occur from medication errors. For evaluation of the Distribution of Prescription Drugs Individualized was a transversal study, which used the technique of participant observation and convenience sampling. Were evaluated prescriptions linked to the Distribution System for Prescription Drug Individualized technology bar code. Results: To evaluate the process of individualization were observed fractionation of 42 oral dosage forms and injectables where routine writing process of individuation attended 66% of the items recommended and play the same 63% attended. For evaluation of the Distribution of Prescription Drugs Individualized analyzed 290 prescriptions linked to the Distribution System for Prescription Drug Individualized of these, 25% had some type of medication error. The total number of items analyzed was 2659, with 74 occurrences of medication errors (2.78%). Compared with earlier data the number of errors per clinic or in general had a statistically significant reduction. Conclusions: The results show that the use of new technologies increases the quality of service by preventing medication errors. Therefore, the system of reading bar codes associated with changes in the infrastructure and work processes can be described as the major factors in reducing the rates of errors in dispensing drugs in the hospital.

博士
國立臺灣大學
健康政策與管理研究所
104
Background Drug safety is an important issue in health care delivery system nowadays. The Institute of Medicine (IOM) has indicated that health information technology (HIT), especially computerized physician order entry system (CPOE) embedded with clinical decision support system (CDS), can assist physicians to avoid inappropriate prescribing, reduce medication errors, and improve care quality. However, the adoption of CPOE/CDS seemed to be different among countries. Many of the previous studies which have conducted surveys on the usage of CPOE/CDS for specific alert items were limited, and only a few reports have assessed the impact or performance of CPOE/CDS. Therefore, this study aimed to understand the adoption of CPOE/CDS among hospitals, and to examine the association of CPOE/CDS adoption and inappropriate prescriptions (include medication duplication and drug-drug interaction) comprehensively in Taiwan. Material & methods In the first part of this study, a cross-sectional questionnaire was developed and mailed to 380 hospitals nationwide between July and September, 2009. The variables listed included: (1) time of adopting CPOE/CDS in the hospitals'' outpatient departments (with 6 time periods: before year 1997, 1998-2000, 2001-2003, 2004-2006, 2007-2009, 2010-2012) , (2) alert conditions and items in the CPOE/CDS, and (3) the operation status of CPOE/CDS (complexity, stability, and maintenance). In the second part, a longitudinal NHI dataset was applied to examine the association between the adoption of the CPOE/CDS system and inappropriate medication at hospital level. We evaluated two kinds of medication duplication and drug-drug interaction alert functions. The first duplicated medication was within a single prescription and was identified as "a patient received drugs with the same therapeutic effect (as defined by level 4th of Anatomical Therapeutic Chemical system) in one prescription", and the medication duplication rate (1) was calculated as (cases of medication duplication) / (total number of prescriptions in a hospital) x 100%. The second duplicated medication was across prescriptions and was defined as " a patient received drugs with the same therapeutic effect in different prescriptions provided by different physicians at the same hospital within one treatment period", and the medication duplication rate (2) was calculated as (the cases of medication duplication) / (total number of prescriptions provided in a hospital within same treatment period) x 100%. Concerning the drug-drug interaction, we only focused on the drugs for diabetes and hypertension treatment in 208 hospitals. We defined the drug-drug interaction (DDI) based on the severity level (contraindicated/major) and evidence level (excellent/good), and the DDI rate was calculated as (the cases of target DDI / total number of target prescriptions provided in a hospital). In the GEE regression models, the adoption time was classified into 6 periods: years before 1997, 1998-2000, 2001-2003, 2004-2006, 2007-2009, and 2010-2011. Hospital''s characteristics were considered in the analysis which included accreditation level, ownership, branch of NHI, the average number of drugs within one prescription, and the average age of patients in outpatient departments. Results A total of 208 hospitals completed and returned the questionnaires with a response rate of 56.8%. Adoption rate of CPOE/CDS increased from less than 10% before year 1997 to 95.83% after 2010. Most of the large-scale hospitals were early adopters and tended to implement advanced systems designed by themselves. After adjusting for related variables, medication duplication rate (1) decreased alone the time significantly (b=-2.3830 for years 1998-2000 and b=-5.5333 for years 2010-2011 with P<0.0001repectively; reference year was 1997), and medication duplication rate (2) also decreased alone the time (b=-5.58164 for 1998-2000 and b=-22.5398 for 2010-2011 with P<0.0001 respectively). However, both of diabetes and hypertension DDI rates were increased after years 2004-2006 (for DM, b=1.0271 for years 2004-2006 and b=2.0035 for 2010-2011 with P<0.0001 respectively; for hypertension, b=0.7288 for years 2004-2006 , P=0.0032 and b=1.7863 for 2010-2011, P<0.0001). Discussion and conclusion In Taiwan, hospitals introduced CPOE/CDS during 1997and 2010 and have reached 95% adoption rate. We found that medication duplication in hospitals has decreased significantly along with the development of hospital''s medication alert system. However, the drug-drug interaction was not decreasing which might be owing to the increased prevalence of chronic conditions and the NHI drug payment design. More detailed evaluation of the impact of medication alert system is needed in the future.

Kan, Ka Lai Carrie.
"May 2008."
Thesis (M.Phil.)--Chinese University of Hong Kong, 2008.
Includes bibliographical references (leaves 118-125).
Abstracts in English and Chinese, some text in appendix also in Chinese.
Chapter CHAPTER 1: --- INTRODUCTION --- p.1
Chapter CHAPTER 2: --- LITERATURE REVIEW
Introduction --- p.3
Medication error --- p.4
Definition of medication error --- p.4
Incidents of medication error --- p.6
The issues of defining medication error --- p.7
The issue of medication error reporting --- p.8
Near miss --- p.9
Factors associated with medication error --- p.10
System factors --- p.10
Environmental factors --- p.12
Human factors --- p.13
Slips and lapses and medication error --- p.14
"Distraction, slips and lapses and medication error" --- p.15
Distraction --- p.15
Definition of distraction --- p.15
Consequences of distraction --- p.16
Factors associated with distraction --- p.16
Cognitive factors --- p.17
Personality factors --- p.18
Environmental factors --- p.18
Studies on distraction during medication administration --- p.19
Distraction and medication error --- p.21
Strategies to reduce distraction --- p.22
Visual Sign --- p.23
Definition of visual sign --- p.23
Nature of visual sign --- p.24
Studies on visual sign to reduce distraction --- p.25
Summary of literature review --- p.25
Chapter CHAPTER 3: --- METHODOLOGY
Introduction --- p.27
Aims and objectives --- p.27
Operational definitions --- p.28
Research design --- p.28
Setting --- p.31
Stage one --- p.32
Setting --- p.32
Sampling --- p.33
Instrument --- p.35
Data collection method --- p.36
Data analysis --- p.37
Stage two --- p.38
Stage three --- p.40
Pilot study --- p.40
Validity and reliability of methodology --- p.41
Interview --- p.41
Observation --- p.42
Ethical considerations --- p.43
Chapter CHAPTER 4: --- FINDINGS
Introduction --- p.44
Stage one --- p.44
Baseline interview --- p.44
Informants' characteristics --- p.44
Categories and sub-categories --- p.45
Feelings of medication error --- p.46
Causes of medication error --- p.47
Causes of distraction --- p.49
Perception of distraction --- p.50
Feelings about distraction --- p.52
Strategies to reduce distraction --- p.53
Strategies to reduce medication error --- p.54
Baseline observation --- p.56
Findings of stage one --- p.59
Stage two --- p.60
One week after implementation observation --- p.60
Findings of stage two --- p.63
Stage three
Three months after implementation observation --- p.63
Follow-up interview --- p.66
Informants' characteristics --- p.66
Categories and sub-categories --- p.67
Conflicting feelings --- p.68
Different effects on nursing service --- p.69
Feelings about wearing the red vest --- p.70
Enhanced a non-distractive culture --- p.72
Improved cognitive process --- p.73
Improved performance --- p.75
Findings of stage three --- p.76
Comparison of the three stages of quantitative observational data --- p.77
"Lapse time, items given, and number of patients" --- p.77
Comparison of lapse time and total distraction --- p.78
Comparison of the ten items on distraction --- p.78
Comparison of total distraction --- p.79
Comparison of near misses --- p.80
Overall Summary of the findings --- p.80
Chapter CHAPTER 5: --- DISCUSSION
Introduction --- p.82
Characteristics of informants and observational data --- p.82
Nurseśة perception of distraction as a cause of medication administration error --- p.83
Causes of distraction during medication administration --- p.87
Evaluation outcome --- p.91
Evaluation process --- p.98
Chapter CHAPTER 6: --- "LIMITATIONS, IMPLICATIONS AND RECOMMEDATIONS"
Limitations --- p.111
Setting --- p.111
Population and sampling --- p.111
Observer's influence --- p.112
Interviewer's influence --- p.112
Implications for nursing practice --- p.113
Recommendations for future studies --- p.114
Conclusion --- p.116
REFERENCES --- p.118
APPENDICES
Chapter 1: --- Literature search --- p.126
Chapter 2: --- Medication Administration Distraction Observation Sheet (MADOS) --- p.127
Chapter 3: --- Adapted MADOS --- p.128
Chapter 4: --- Baseline interview guide --- p.129
Chapter 5: --- Interview consent form --- p.130
Chapter 6: --- Observation consent form --- p.136
Chapter 7: --- Informal letter to nursing staff --- p.142
Chapter 8: --- Follow-up interview guide --- p.144
Chapter 9: --- Rationale for pilot study --- p.145
Chapter 10: --- Ethical approval (CUHK) --- p.147
Chapter 11: --- Ethical approval ( Hospital Administrative Council) --- p.148
Chapter 12: --- Baseline interview (1) --- p.149
Chapter 13: --- Baseline observation (MAC 4) --- p.154
Chapter 14: --- One week after observation (MAC 01) --- p.155
Chapter 15: --- Three months after observation (MAC 005) --- p.156
Chapter 16: --- Follow-up interview (08) --- p.157
TABLES
Chapter 1: --- Different units and the approximate numbers of nurses --- p.30
Chapter 2: --- Proposed sample size for baseline interview --- p.33
Chapter 3. --- Medication administration at different scheduled time --- p.35
Chapter 4. --- Informantśة characteristics at baseline interview --- p.45
Chapter 5: --- Categories and subcategories: baseline interview --- p.46
Chapter 6: --- "Elapse time, items given, number of patients, distractions and near misses at baseline observation" --- p.57
Chapter 7: --- Frequency of the ten items of distraction at baseline observation --- p.57
Chapter 8: --- Ranking of the ten items on distraction at baseline observation --- p.58

Yes
Introduction: The complex healthcare system that provides patients with medicines places them at risk when care is transferred between healthcare organisations, for example discharge from hospital. Consequently, under-standing and improving medicines management, particularly at care transfers, is a priority.Objectives: This study aimed to explore the medicines management system as patients experience it and determine differences in the patient-perceived importance of people in the system.Methods: We used a Social Network Analysis framework, collecting ego-net data about the importance of people patients had contact with concerning their medicines after hospital discharge. Single- and multi-level logistic regression models of patients' networks were constructed, and model residuals were explored at the patient level.This enabled us to identify patients' networks with support tie patterns different from the general patterns suggested by the model results. Qualitative data for those patients were then analysed to understand their differing experiences.Results: Networks comprised clinical and administrative healthcare staff and friends and family members.Networks were highly individual and the perceived importance of alters varied both within and between patients. Ties to spouses were significantly more likely to be rated as highly important and ties to community pharmacy staff (other than pharmacists) and to GP receptionists were less likely to be highly rated. Patients with low-value medicines management networks described having limited information about their medicines and alack of understanding or help. Patients with high-value networks described appreciating support and having confidence in staff.Conclusions: Patients experienced medicines management as individual systems within which they interacted with healthcare staff and informal support to manage their treatment. Multilevel models indicated that there are unexplained variables impacting on patients' assessments of their medicines management networks. Qualitative exploration of the model residuals can offer an understanding of networks that do not have the typical range of support ties.
National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC)

There are 353 NHS hospitals in the United Kingdom, and within these hospitals there is wide variation in the electronic prescribing systems applied. Indeed, only one hospital uses a single system in all of its clinical areas. Medication error is the biggest issue in the health care profession in respect to patient safety—

碩士
亞洲大學
資訊工程學系碩士班
94
PURPOSE: Previous studies found that medication errors often resulted from insufficient critical information during prescribing stages. Therefore, it is proposed pharmacists checking of the prescriptions may reduce the likelihood of preventable slips and mistakes. The objective of this study is to apply a simultaneous web-based prescription checking system having pharmacists’ participation during the physicians prescribing steps to ensure the patient safety. METHODS: The designs of this system are to analyze potential accidents in prescription sending processes and correct them. Many authors propose a restricted High Alert Medications system, to check against medication administrations, and make any efforts to reduce the prescription errors. RESULTS: A web-based alert system was designed so that pharmacists could intervene then reduce prescribing errors through High Alert Medications and adverse drug reaction messages. Physicians could confirm the errors questioned by pharmacists through such system. CONCLUSIONS: This web-based alert system designed by the authors may reduce medication errors and improve patient safety.

碩士
臺北醫學大學
醫務管理學研究所
102
Background and Objectives: Many countries have committed to improving patient safety in medical institutions in recent years. A study by the Institute of Medicine illustrated that medical errors cause 98,000 to 44,000 deaths each year. In order to avoid medical errors, reduce medical costs and improve patient safety, hospitals and governments around the world have begun to implement various types of medical information systems to reduce medication errors. Currently, the medical barcode system and automatic identification systems are considered very effective programs. The implementation of medical barcode systems in hospital pharmacies can significantly reduce medication errors. Barcode systems can not only allow for the exchange of patient data with other hospitals and reduce the waste of medical resources, but also can assist integration with the drug suppliers to increase inventory turnover as well as reduce inventory and procurement personnel costs. In so doing, hospitals may improve the quality of healthcare. The purpose of this research is to identify the factors affecting intention and adoption behaviors for using barcode medication administration systems in hospitals Methods: This research utilizes cross-sectional study methods. The structured questionnaire framework is based on the Technology–Organization–Environment perspective. The study addressed the head of the Department of Pharmacy at facilities including academic medical centers, metropolitan hospitals and local community hospitals. A total of 497 questionnaires were distributed and 220 were returned, for a recovery rate or 44.3%. SPSS v18.0 and AMOS v18.0 were used for descriptive statistics and Structural Equation Modeling (SEM). Results: In this study, the SEM chi-square value/degrees of freedom are 2.115, GFI is 0.922, AGFI of 0.874, and RMSEA is 0.071. Environmental frame surface to intention was significant, the total utility is 0.55, and total utility of intention to behavior is 0.184. Different types of hospitals have different levels of medication barcode system usage, and the proportion of drugs using a medication barcode system is higher in academic medical centers than in metropolitan hospitals and local community hospitals. Conclusion: Environmental frame to intention was significant, and intention affects behavior. Government agencies should be required to establish policies and provide adequate incentives to increase the use of medication barcode systems.

碩士
國立東華大學
企業管理學系
105
Medical is a highly labor-intensive industries, hospital personnel cost (about 45% to 50%) is usually the highest rate of the total cost of the hospital. Therefore, how to manage and effectively utilize the human resources will impact overall operation performance of the hospital. Since January 1, 2016, the statutory normal working hours from 42 hours per week reduced to 40 hours per week, add to start the implementation of "one-off" policy in 2017, the increase in overtime pay is undoubtedly a heavy burden on the employers, and the medical institutes will face even greater changes and challenges in an increasingly harsh medical environment. Usually, the allocation of manpower relies on the experience of field supervisors and post-mortem review to modify the manpower configuration. In this study, according to case in July 2016 to September 2016 outpatient service volume, a system dynamic simulation model is used to simulate cashier and medication of manpower, and through manpower increase and decrease of situation to explore people waiting time. With the relevant data, this study shows that the system simulation could help managers to find the best combination of human resources, effective control of labor costs, and have a good quality of service. The results serve as an important reference index for manpower planning.

背景:越來越多證據支持在醫院實行電子醫囑系統(CPOE)可以有效減少用藥錯誤，但CPOE可能會影響藥物應用時間，對病人護理效率有潛在的影響，本研究的系統評價結果顯示，CPOE與手寫醫囑比較下，CPOE能有效地減低整體藥物應用時間, 特別是由處方至配藥程序的時間，但CPOE對於派藥時間的影響卻未能確定。
研究目的：本準實驗性研究在於探討CPOE對護士派藥時間的潛在影響，及此系統對於護理品質的影響。
研究方法：本研究採取一個非隨機化的實驗設計，以直接觀察及時間和運行方法收集資料，研究地點是一間香港社區醫院，實驗組為一間已實行CPOE的內科病房，對照組為一間仍以手寫醫囑派藥的腫瘤科病房，本研究共收集了由二十五位護士執行的一百二十個派藥時間（每個病房各有六十個），為了要控制護士的聚類效果及潛在混淆變數的影響，使用Generalized Estimating Equation (GEE) 以比較兩組的派藥時間差矩，同時收集實驗組在實行CPOE開始之前及後六個月內的護理品質指標以作比較，包括：病人跌倒率、褥瘡率、藥物事故數目、及病人平均住院日數等。
結果：CPOE派藥與手寫醫囑比較下，前者使用較短的派藥時間（CPOE：Mean = 43.42 + 23.99秒 Vs 手寫醫囑：Mean = 79.9 +57.63秒），而且CPOE對於縮短派藥時間有統計學上的重大效果 ( Mann-Whitney U test= - 4.78, p < 0.001 ) ( d = 0.63) ， 當使用GEE控制護士的聚類效果及五種潛在混淆變數的影響，包括:護士的畢業年資、在病房的工作年資、藥物的製備形式、派給每位病人的藥物數目、需要搗碎的藥物等，GEE結果顯示每種藥的平均派藥時間仍然保持統計學上的重大效果 (β=49.096, SE=8.08, p<0.001) ，GEE結果：平均派藥時間與派給每位病人藥物之數目有統計學上的負面關聯 ( β = -18.202, SE = 2.22, p < 0.001 )，而平均派藥時間與每位病人所派漱口水數目有統計學上的正面關聯 (β = 38.38, SE = 10.35, p <0.001)，醫院統計報告顯示，實驗組在實行CPOE後四種護理品質指標並無明顯差矩。
總結：本研究結果進一步支持CPOE對縮短護土派藥時間有正面影響，此證據可以增強護士在日常工作使用CPOE的認受性，本研究亦提供了一個對CPOE效果大小的估計，為未來類似研究時計算樣本所需數目以作參考，建擬進一步的研究要使用足夠的統計力量及完善的研究設計以檢測CPOE對護理品質的影響。
Background: There is a growing body of evidence that supports the implementation of computerized physician order entry (CPOE) systems into the hospital settings. While it is useful to prevent medication errors, CPOE might have a potential impact on the efficiency of patient care by affecting the medication turnaround time (TAT). Our systematic review found that as compared to handwritten prescription, CPOE was effective on reducing overall medication TAT, and time from prescribing to pharmacy processing, but its effect on medication administration phase was inconclusive.
Objectives: The purpose of this pilot study is to explore the impact of CPOE on medication administration time by nurses as compared to hand-written prescription and its potential effect on quality of care.
Methodology This study utilizes a non-randomized experimental design using a direct observational and time motion study approach. Data were collected in one medical ward using CPOE and one Oncology ward using handwritten prescription in a regional hospital in Hong Kong. The medication administration time for a total of 120 prescriptions (60 per ward) administered by 25 nurses was collected. Generalized Estimating Equation (GEE) compared the difference in medication administration time between the two groups controlling the clustering effects of nurses and the effects of potential confounders. Quality indicators including patient’s fall rate, pressure ulcer rate, number of medication incidence, and average length of stay of the experimental site were retrieved from hospital statistical reports 6 months prior and after the implementation of CPOE.
Findings The medication administration time using CPOE ( Mean = 43.42 + 23.99 sec.) was shorter when compared with hand-written prescription (Mean = 79.9 + 57.63 sec) which is a statistically significant (Mann-Whitney U test = - 4.78, p < 0.001 ) with a large effect size ( d =0.63). GEE results also revealed that the average medication administration time per drug remained statistically significant between the experimental and control groups (ß=49.096, SE=8.08, p<0.001) after controlling the clustering effect of nurses and the effect of five confounders ( year of post-graduate experience, working experience in ward, number of medication administered to each patient, different forms of medication administered, and medication required to be crushed). GEE results revealed that the medication administration time was statistically associated with number of medication administered negatively (ß = -18.202, SE = 2.22, p < 0.001 ) and number of mouth wash administered positively (ß = 38.38, SE = 10.35, p < 0.001 ). The hospital statistical reports in the experimental site showed no significant difference in all the four quality of care indicators.
Conclusion The findings of the study provide further support to the positive impact of CPOE on reducing the medication administration time by nurses. This could serve as an evidence to enhance nurses’ acceptance of this system into their daily practice. This study also provides an estimate of the effect size of CPOE which could enable accurate sample size determination in further studies in a similar context. Further studies with sufficient statistical power and better study design are needed to detect its effect on quality of care.
Cheung, Man Ching Nancy.
Thesis D.Nurs. Chinese University of Hong Kong 2016.
Includes bibliographical references (leaves ).
Abstracts also in Chinese.
Title from PDF title page (viewed on …).
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.

O presente trabalho divide-se em três capítulos e tem como base as três vertentes inseridas no meu Estágio Curricular, presente no plano de estudos do Mestrado Integrado em Ciências Farmacêuticas: Investigação, Farmácia Comunitária e Farmácia Hospitalar. O primeiro capítulo diz respeito ao trabalho de investigação que desenvolvi relativamente aos métodos tecnológicos inovadores para a monitorização da adesão à terapêutica medicamentosa. Nos tempos que correm, verificamos que uma percentagem significativa da população mundial tem necessidade de tomar medicação e de controlar e/ou tratar, tanto as patologias agudas como as crónicas. A avaliação da adesão à terapêutica medicamentosa e o conhecimento dos diversos fatores que a influenciam são determinantes para o desenvolvimento de estratégias, por parte dos diversos profissionais de saúde, tendo em vista aumentar essa mesma adesão, fundamental para o controlo eficaz e eficiente das doenças crónicas e para a prevenção de muitas das complicações graves que lhes estão associadas. Existem sistemas eletrónicos, como o Medication Event Monitoring System (MEMS), o Short Message Service (SMS) e, mais recentemente, uma tecnologia à base de circuitos integrados (CIs) digeríveis que se revelaram promissores na avaliação da adesão à terapêutica medicamentosa. Estes sistemas/tecnologias permitiram ultrapassar muitas das desvantagens associadas aos métodos de avaliação da adesão à terapêutica correntemente utilizados. Foi efetuada uma revisão da literatura envolvendo todos os artigos que mencionam as tecnologias anteriormente mencionadas, para a avaliação da adesão à terapêutica medicamentosa. Foram igualmente consultados os sites oficiais das empresas norte-americanas (MWV Healthcare, Richmond, VA, USA e Proteus Biomedical, Inc., Redwood City, CA, USA) e também o site da revista Journal of Health Informatics. A restante pesquisa bibliográfica foi realizada através dos termos “medication adherence technology” e “new techonologies to improve therapeutic adherence” consultados no PubMed. O MEMS envolve frascos para colocação da terapêutica que contêm um circuito eletrónico que faz o registo do número de vezes, data e hora que o frasco foi aberto e fechado. Os eventos são registados e transferidos por wireless para um computador. O SMS envolve o envio de mensagens por via rede móvel aos doentes, como alerta para a toma da medicação. Por último, o outro sistema eletrónico consiste num sensor digerível, constituído por um CI revestido por magnésio e cobre, incorporado nas formas farmacêuticas orais sólidas. Este sensor é ativado pelo fluido gástrico, emitindo um sinal para um detetor portátil, o qual permite o registo da hora/data da toma e também de diversos dados fisiológicos do doente (p. ex., pressão arterial, frequência cardíaca, temperatura). É possível diferenciar os medicamentos que o doente toma, através da variação do CI utilizado. O detetor permite a transmissão a um servidor que integra os dados com outros dispositivos sem fios. Periodicamente, são gerados relatórios resumidos para o doente e para os profissionais de saúde. O sistema apresenta uma elevada sensibilidade e especificidade e uma excelente precisão de identificação dos diversos sensores digeríveis. Estas tecnologias constituem uma prática inovadora para a avaliação da adesão à terapêutica medicamentosa administrada por via oral, apresentando, indiscutivelmente, uma grande aplicabilidade na esfera profissional dos farmacêuticos. O segundo e terceiro capítulos são o resultado do meu estágio em Farmácia Comunitária e Farmácia Hospitalar, respetivamente. Ambos os períodos de estágio permitiram-me entender a função e a importância do farmacêutico no ato da sua profissão, relatando assim alguns dos conhecimentos e competências que adquiri.