FEELINGS EXPERIENCED BY NURSING TEAMS AFTER THE OCCURRENCE OF MEDICATION ERRORS
DOI:
https://doi.org/10.5380/ce.v21i5.45411Keywords:
Emotions, Medication errors, Safety management, Nursing care, Patient safety.Abstract
The present study aimed to identify the feelings experienced by nursing teams regarding medication errors and the strategies used to prevent them. Exploratory and descriptive study carried out in a hospital in Minas Gerais, Brazil,in2014. Data was collected through semi-structured interviews Semi-structured interviews were conducted with the eleven participants. Four categories emerged from thematic analysis: 1) inadequate conceptualization of error, 2) negative feelings associated to the error, 3) Nurses’ responses to medication errors;and 4) strategies for preventing medication errors. Inability to define error was observed; perception of a feeling of fear not related to punishment; the existence of skills/competences, responsibility and communication in response to error, and the use of barriers and strategies recommended for the prevention of errors. The implementation of continuous awareness of safety as a strategy to improve learning, disseminate assertive behaviors of the professionals and promote actions to mitigate the feelings of those involved in medication errors is suggested.
References
Casos Stephanie e Mariana: onde cabe o direito e o dever. Rev Enferm [Internet]. dez 2010 [acesso em: 11 nov 2015];11(87):54. Disponível em: http://www.coren-sp.gov.br/sites/default/files/revista_enfermagem_dezembro_2010_0.pdf
National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP Taxonomy of medication errors [Internet]. 31 jul 2001 [acesso em: 11 nov 2015]. 19 p. Disponível em: http://www.nccmerp.org/sites/default/files/taxonomy2001-07-31.pdf
Feldman LB, organizadora. Gestão de risco e segurança hospitalar: prevenção de danos ao paciente, notificação, auditoria de risco, aplicabilidade de ferramentas, monitoramento. São Paulo: Martinari; 2008. 392 p.
Silva AE, Cassiani SH. Errors of medication in a University Hospital: type, causes, suggestions and actions. Rev Bras Enferm [Internet]. 2004 [acesso em: 11 nov 2015];57(6):671-4. Disponível em: http://www.scielo.br/pdf/reben/v57n6/a07.pdf
Fonseca AS, Peterlini FL, Costa DA, organizadoras. Segurança do paciente. São Paulo: Martinari; 2014.
Ministério da Saúde (BR). Portaria n. 529 de 1 de abril de 2013. Institui o Programa Nacional de Segurança do Paciente (PNSP). Diário Oficial da União [Internet]. 2 abr 2013 [acesso em: 11 nov 2015];Seção 1:43. Disponível em: http://www.jusbrasil.com.br/diarios/52582397/dou-secao-1-02-04-2013-pg-43
Associação Brasileira de Normas Técnicas. NBR ISO 31000: Gestão de riscos: princípios e diretrizes [Internet]. Rio de Janeiro: Associação Brasileira de Normas Técnicas; 2009 [acesso em: 11 nov 2015]. Disponível em: http://www.totalqualidade.com.br/2010/06/abnt-nbr-iso-31000-principios-da-gestao.html
Corbellini VL, Schilling MC, Frantz SF, Godinho TG, Urbanetto J de S. Medication-related adverse events: perception of nursing aides. Rev Bras Enferm [Internet]. mar-abr 2011 [acesso em: 11 nov 2015];64(2):241-7. Disponível em: http://www.scielo.br/pdf/reben/v64n2/a04v64n2.pdf
Shimabukuro PM, Paulon P, Feldman LB. Implementation of bundles in intensive care unit: an experience report. Rev Enferm UFSM [Internet]. jan-mar 2014 [acesso em: 11 nov 2015];4(1):227-36. Disponível em: http://cascavel.ufsm.br/revistas/ojs-2.2.2/index.php/reufsm/article/view/11097/pdf
Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system [Internet]. Washington (DC): National Academy Press; 2000 [acesso em: 11 nov 2015]. Disponível em: http://www.nap.edu/read/9728/chapter/1
Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 9 set 2002;162(16):1897-903.
Minayo MC. O desafio do conhecimento: pesquisa qualitativa em saúde. 12a ed. São Paulo: Hucitec; 2010. 407 p.
Organização Nacional de Acreditação. Manual Brasileiro de Acreditação: Organizações Prestadoras de Serviços de Saúde. São Paulo: ONA; 2014.
Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety: Drawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring [Internet]. London: Health Foundation; 2013 [acesso em: 11 nov 2015]. Disponível em: http://www.health.org.uk/sites/default/files/TheMeasurementAndMonitoringOfSafety_fullversion.pdf
Telles Filho PC, Praxedes MF, Pinheiro ML. Measurement errors: analysis of the nursing staff's knowledge in a hospital. Rev Gaucha Enferm [Internet]. set 2011 [acesso em: 11 nov 2015];32(3):539-45. Disponível em: http://www.scielo.br/pdf/rgenf/v32n3/15.pdf
National Patient Safety Foundation. Patient safety dictionary [Internet]. Boston (MA): National Patient Safety Foundation; c2015 [acesso em: 11 nov 2015]. Disponível em: http://www.npsf.org/?page=dictionaryae
World Health Organization. Health topics: hospitals [Internet]. Geneva: World Health Organization; c2015 [acesso em: 11 nov 2015]. Disponível em: http://www.who.int/topics/hospitals/en/.
Schoen TH, Vitalle MS. What am I afraid of? Rev Paul Pediatr [Internet]. 2012 [acesso em: 11 nov 2015];30(1):72-8. Disponível em: http://www.scielo.br/pdf/rpp/v30n1/en_11.pdf
Sarquis LM, Felli VE. The feelings experienced after occupational exposure among health care workers: fulcrum approach to work in health institutions. Rev Bras Enferm [Internet]. set-out 2009 [acesso em: 11 nov 2015];62(5):701-4. Disponível em: http://www.scielo.br/pdf/reben/v62n5/08.pdf
Padilha KG, Kitahara PH, Goncalves CC, Sanches AL. Iatrogenic events with medications at the intensive care unit: procedures and feelings expressed by nurses. Rev Esc Enferm USP [Internet]. mar 2002 [acesso em: 11 nov 2015];36(1):50-7. Disponível em: http://www.scielo.br/pdf/reeusp/v36n1/v36n1a07.pdf
Bohomol E, Ramos LH. Perceptions about medication errors: analysis of answers by the nursing team. Rev Lat Am Enferm [Internet]. nov-dez 2006 [acesso em: 11 nov 2015];14(6):887-92. Disponível em: http://www.scielo.br/pdf/rlae/v14n6/v14n6a09.pdf
Santos JO, Silva AE, Munari DB, Miasso AI. Conducts adopted by nursing technicians after the occurrence of medication errors. Acta Paul Enferm [Internet]. maio-jun 2010 [acesso em: 11 nov 2015];23(3):328-33. Disponível em: http://www.scielo.br/pdf/ape/v23n3/en_v23n3a03.pdf
Elliott M, Liu Y. The nine rights of medication administration: an overview. Br J Nurs. 11-24 mar 2010;19(5):300-5.
Ministério da Saúde (BR); Agência Nacional de Vigilância Sanitária (BR); Fundação Oswaldo Cruz; Fundação Hospitalar do Estado de Minas Gerais, coordenadores. Protocolo de segurança na prescrição, uso e administração de medicamentos [Internet]. Brasília: Agência Nacional de Vigilância Sanitária; 2013 [acesso em: 11 nov 2015]. 45 p. Disponível em: http://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/item/seguranca-na-prescricao-uso-e-administracao-de-medicamentos
Lameu CA, Corazza E. Estratégias para minimizar o erro na administração de medicamentos. Rev Enferm UNISA [Internet]. 2010 [acesso em: 14 nov 2015];11(2):100-3. Disponível em: http://www.unisa.br/graduacao/biologicas/enfer/revista/arquivos/2010-2-07.pdf
Downloads
Published
How to Cite
Issue
Section
License
Cogitare Enfermagem reserves the right to make normative, orthographic, and grammatical changes to the published article to maintain the cultured standard of the language, while respecting the authors' style.
The published study is the sole responsibility of the author(s), and Cogitare Enfermagem is exclusively responsible for evaluating the manuscript as a scientific publication vehicle. Revista Cogitare Enfermagem is not responsible for any violations of Law No. 9,610/1998, the Brazilian Copyright Law.
Cogitare Enfermagem allows the author to hold the copyright of articles accepted for publication, without restrictions.
The articles published are licensed under the Creative Commons license CC BY 4.0 Creative Commons - Attribution 4.0 International - CC BY 4.0 - The attribution adopted by Cogitare Enfermagem is permitted:
- Share - copy and redistribute the material in any media or format.
- Adapt - remix, transform and build upon the material for any purpose, even commercially.
- Attribution - You must give proper credit, provide a link to the license, and indicate if changes have been made. You may do this in any reasonable way, but not in a way that suggests that the licensor endorses it or approves of its use.
- No additional restrictions - You may not apply legal terms or technological measures that legally restrict others from doing something that the license allows.
