Manoel de Carvalho1, Alan A Vieira. 1. Saúde da Mulher e da Criança, Universidade Federal Fluminense, RJ. manoel@perinatal.com.br
Abstract
OBJECTIVE: To review the current literature and to discuss medical errors in hospitalized patients emphasizing its incidence, predisposing factors and prevention mechanism. Special attention is given to medication errors and adverse drug events in newborn infants and pediatric patients. SOURCES: Bibliographic review of the current literature through electronic search in Medline data-base, with selection of the most relevant articles. SUMMARY OF THE FINDINGS: Even though most medical errors are not reported, it is important to notice that its incidence is greater than previously assumed. In the USA, approximately one million of patients/year are victims of medical errors and adverse drug events. Today, deaths resulting from these episodes are the fourth cause of mortality in the USA. In neonatal and pediatric intensive care units, where the complexity and frequency of technical procedures are high, medical errors are frequent. Fifteen percent of all admissions to a neonatal intensive care unit is followed by medical errors. Most of these errors occur during night shifts and include incorrect administration of drugs (35%) and errors regarding the interpretation of medical prescription (26%). Environmental factors (noise, heat), psychological factors (anxiety, stress) and physiologic factors (fatigue, absence of sleep) contribute to the occurrence of errors. Recent study shows that after working 24 hours without sleeping, the performance of a health professional is similar to a legally drunk person (serum alcohol level > or =0.08%). CONCLUSIONS: Errors are part of human behavior. The prevention of errors should include a careful review of the organizational system. Medical errors should be seen as an opportunity to change or re-structure the system and to improve the quality of health care delivered and patient safety.
OBJECTIVE: To review the current literature and to discuss medical errors in hospitalized patients emphasizing its incidence, predisposing factors and prevention mechanism. Special attention is given to medication errors and adverse drug events in newborn infants and pediatric patients. SOURCES: Bibliographic review of the current literature through electronic search in Medline data-base, with selection of the most relevant articles. SUMMARY OF THE FINDINGS: Even though most medical errors are not reported, it is important to notice that its incidence is greater than previously assumed. In the USA, approximately one million of patients/year are victims of medical errors and adverse drug events. Today, deaths resulting from these episodes are the fourth cause of mortality in the USA. In neonatal and pediatric intensive care units, where the complexity and frequency of technical procedures are high, medical errors are frequent. Fifteen percent of all admissions to a neonatal intensive care unit is followed by medical errors. Most of these errors occur during night shifts and include incorrect administration of drugs (35%) and errors regarding the interpretation of medical prescription (26%). Environmental factors (noise, heat), psychological factors (anxiety, stress) and physiologic factors (fatigue, absence of sleep) contribute to the occurrence of errors. Recent study shows that after working 24 hours without sleeping, the performance of a health professional is similar to a legally drunk person (serum alcohol level > or =0.08%). CONCLUSIONS: Errors are part of human behavior. The prevention of errors should include a careful review of the organizational system. Medical errors should be seen as an opportunity to change or re-structure the system and to improve the quality of health care delivered and patient safety.