Assessing risk of medication errors: a case study in a teaching hospital

Ana Maria Saut, Jose Daniel Rodrigues Terra, Fernando Tobal Berssaneti, Marcelo Ramos Martins


In the health care process, patients are subjected to different hazards. Medication error is one of the most frequent causes of adverse events in hospitals. A risk assessment can provide evidence for the development of an action plan to mitigate, reduce or eliminate these hazards. The objective is to evaluate the risks to patients in the process of drug administration in a university hospital. A case study was carried out in a Brazilian teaching hospital with the use of the Failure Modes and Effects Analysis (FMEA) technique. Failures considered as high risks to cause adverse events to patients are exchange of drugs delivered for dispensing, drug identified with the wrong label at the unitization process, lack of prescription standard for dose abbreviation, patient exchange due to inattention or name similarity, request for emergency care without prescription, and drug sent on the wrong shift. The use of FMEA was suitable for the identification and prioritization of risks, providing a basis to develop an action plan to enhance safety.

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Revista Gestão & Saúde (ISSN 19824785)

Revista coordenada pelo Nucleo de Estudos em Educação, Promoção da Saúde e Projetos Inclusivos (NESPROM), do Centro de Estudos Avançados Multidiciplinares (CEAM), da Universidade de Brasília (UnB).

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