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Acta Paulista de Enfermagem

Print version ISSN 0103-2100


YAMAMOTO, Michiko Suzuki; PETERLINI, Maria Angélica Sorgini  and  BOHOMOL, Elena. Spontaneous reporting of medication errors in pediatric university hospital. Acta paul. enferm. [online]. 2011, vol.24, n.6, pp.766-771. ISSN 0103-2100.

OBJECTIVE: To analyze medication errors notified at a pediatric teaching hospital in São Paulo city. METHOD: Retrospective and descriptive study in which 120 error events and 115 spontaneous notifications were analyzed, between January 2007 and December 2008. RESULTS: The error rate was 1.15 per 1000 patients-day; 27.5% of notifications referred to the school age range and the Pediatric ICU was the sector with most notifications. The error type related to wrong infusion speed predominated (25%). The human factor dimension in the performance deficit category (54%) was the most frequent cause of error events. CONCLUSION: The safety culture is a continuous process in institutions and the notification of adverse events is part of the strategies. Improvement measures should be incorporated based on their analysis, whether related to the review of the work process or to team training

Keywords : Medication errors; Pediatrics; Nursing; Notice.

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