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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234


TEIXEIRA, Thalyta Cardoso Alux  and  CASSIANI, Silvia Helena De Bortoli. Root cause analysis: evaluation of medication errors at a university hospital. Rev. esc. enferm. USP [online]. 2010, vol.44, n.1, pp.139-146. ISSN 0080-6234.

The objectives of this study were to identify and analyze the types of medication errors observed in doses prepared and administered differently from those prescribed. It is a descriptive study using the root cause analysis method, 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. Dose errors (24.3%), schedule errors (22.9%) and unauthorized medication administration errors (13.5%) were the most frequent. Hence, medication errors were identified, and root cause analysis was performed, leading to the identification of multiple factors that contributed to error occurrence. Strategies and recommendations were presented for the prevention of errors.

Keywords : Medication systems, hospital; Medication errors; Safety management; Risk management; Nursing.

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