Patient safety: analysing intravenous medication preparation in a sentinel network hospital in brazil

Flavia Giron Camerini Lolita Dopico da Silva About the authors

This study aimed to identify the frequency of errors occurring in intravenous medication preparation and to discuss the possible consequences of these errors to patients. This cross-sectional, observational survey was carried out in three units of one hospital, observing 365 intravenous drug doses prepared by 35 technicians. Data was collected in January and February of 2008. Errors rates above 70.00% were found in all units. The errors were grouped into the categories: needle exchange, ampoule disinfection, cleaning the countertop, wrong time, and wrong dose. The error rates were higher than 50.00% in all categories, except for wrong dose (6.58%). The microbiological safety of the procedure may have been affected, increasing the chance of patient harm in cases of solution contamination. Preparation at the wrong time, applying an hour early, occurred with tenoxicam and dipyrone. The stability of the medication may have been compromised, causing changes to the expected therapeutic results, opening further possibilty for undesirable consequences for patients.

Medication errors; Nursing; Security measures


Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem Campus Universitário Trindade, 88040-970 Florianópolis - Santa Catarina - Brasil, Tel.: (55 48) 3721-4915 / (55 48) 3721-9043 - Florianópolis - SC - Brazil
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