Prescribing errors in a Brazilian teaching hospital: Causes and underlying factors from the perspective of junior doctors.

INTRODUCTION: In university hospital settings most prescriptions are written by junior doctors, who are more likely to make prescribing errors than experienced doctors. Prescribing errors can cause serious harm to patients and drug harm differs among low, middle and high-income countries. In Brazil, few studies have investigated the causes of these errors. Our aim was to explore medication prescribing errors in a teaching hospital, their causes, and underlying factors from the perspective of junior doctors. METHOD: Qualitative, descriptive and exploratory study that used a semi-structured individual interview with questions related to the planning and execution of prescriptions. It was conducted with 34 junior doctors who graduated from twelve different universities located in six Brazilian states. The data were analyzed according to the Reason's Accident Causation model. RESULTS: Among the 105 errors reported, medication omission stood out. Most errors resulted from unsafe acts during execution, followed by mistakes and violations. Many errors reached the patients; unsafe acts of rule violations and slips accounted for the majority. Work overload and time pressure were the most frequently reported causes. Difficulties faced by the National Health System and organizational problems were identified as latent conditions. CONCLUSION: The results reaffirm international findings about the severity of prescribing errors and the multifactorial aspect of their causes. Unlike other studies, we found a large number of violations, which, from the interviewees' perspectives, are related to socioeconomic and cultural patterns. The violations were not seen or mentioned by the interviewees as violations, but as difficulties in accomplishing their tasks on time. Knowing these patterns and perspectives is important for implementing strategies to improve the safety of both patients and professionals involved in the medication process. It is suggested that the exploitation culture of junior doctors' work be discouraged and that their training be improved and prioritized.

Deficiência auditiva neurossensorial associada à doença de Kawasaki / Sensorineural hearing loss associated with Kawasaki disease

Objetivo: a doença de Kawasaki (DK) é uma vasculite sistêmica idiopática, autolimitada, de pequenos e médios vasos. Foram descritos na literaura treze casos de deficiência auditiva neurossensorial, durante a evolução dessa doença. Descreve-se o caso de um lactente com doença de Kawasaki com evolução, durante a fase aguda, para deficiência auditiva neurossensorial. A descrição do caso justifica-se por ilustrar uma complicação grave da DK, pouco mencionada na literatura, que reforça a recomendação de cautela na avaliação global destes pacientes. Descrição: menino hígido de 1 ano e sete meses de idade apresentou-se com febre diária persistente, iniciada havia sete dias, associada à irritabilidade,conjutivite bilateral não-exsudativa, reitema máculo-papular em tronco. Evoluiu com artrite em punhos, cotovelos, joelhos e tornozelos e edema e descamação de mãos e pés, que impossibilitava a deambulação. O diagnóstico de doença de Kawasaki foi estabelecido de acordo com os critérios da American Heart Association (AHA), e a criança foi tratada de forma convencional. Houve regressão das manifestações clínicas três dias após o inicio do tratamento. Contudo, um mês após o início dos sintomas, os familiares notaram resposta insatisfatória a estímulos sonoros. A avaliação da acuidade auditiva através do BERA (Brainstem Evoked Responses Audiometry - Audiometria de Potenciais Evocados de Tronco Cerebral) disgnosticou perda auditiva neurossensorial bilateral, grau severo a profundo. Comentários: é possível que o exame rotineiro de acuidade auditiva em crianças com doença de Kawasaki possa identificar precocemente a deficiência auditiva neurossensorial

[Sensorineural hearing loss associated to Kawasaki Disease] / Deficiência auditiva neurossensorial associada à doença de Kawasaki.

OBJECTIVE: Kawasaki disease is a systemic idiopathic self-limited vasculitis of small and medium-sized vessels. Thirteen cases of sensorineural hearing loss during the evolution of this disease have been described in the literature. We describe a case of an infant with Kawasaki disease who developed sensorineural hearing loss during the acute phase. This case report shows a complication of Kawasaki disease, with few citations in literature, enhancing the importance of careful evaluation of these patients. DESCRIPTION: Nineteen-month-old-boy, formerly healthy, with persistent daily fever seven days before admission, associated with irritability, bilateral nonexudative conjunctivitis and maculopapular erythema on his trunk. There was later development of arthritis on wrists, elbows, knees, and ankles, and swelling associated with desquamation of hands and feet, which prevented him from walking. The diagnosis of Kawasaki disease was established according to the American Heart Associations criteria, and the child was conventionally treated. There was regression of clinical manifestations three days after the beginning of treatment. However, one month after the onset of symptoms, the family noticed an unsatisfactory response to sound stimuli. The evaluation of auditory acuity through BERA (Brainstem Evoked Responses Audiometry) revealed severe bilateral sensorineural hearing loss. COMMENTS: Routine examination of auditory acuity in children with Kawasaki disease may help identify sensorineural hearing loss at an early stage.

Osteomielite crônica recorrente multifocal diagnosticada inicialmente como espondilite tuberculosa / Chronic recurrent multifocal osteomyelitis misdiagnosed as tuberculous spondylitis

Esse caso ressalta a importância da osteomielite crônica recorrente multifocal para o diagnóstico diferencial das espondilites infecciosas. Menina, nove anos de idade, com história de febre intermitente, artrite em joelhos e tornozelos e dor na coluna torácica lombar havia seis meses. Ao exame físico observaram-se escoliose e limitação importante da flexão da coluna toracolombar. Os exames laboratoriais revelaram discreta leucocitose, elevação das proteínas de fase aguda ePPD não reator. A radiografia simples e a tomografia de coluna evidenciaram redução de altura do corpo vertebral de L1 e do interespaço do disco L3-L4 com ponte óssea entre estes corpos vertebrais e osteocondensação dos platôs vertebrais. A hipótese inicial foi de mal de Pott e a paciente foi tratada com esquema convencional para tuberculose óssea por seis meses. Houve melhora importante da deformidade de coluna, mas persistiram os episódios de dores articulares e edema em joelhos e tornozelos. A radiografia simples de tornozelo esquerdo revelou lesão osteolítica de contorno geográfico com esclerose marginal em região metafisária da tíbia. A biópsia de fragmento ósseo de tíbia mostrou fibrose medular e cultura negativa. Nova tomografia de coluna revelou aumento das dimensões e da densidade das áreas de osteocondensação sem comprometimento de partes moles adjacentes. Esses achados são sugestivos de osteomielite crônica recorrente multifocal. Embora rara, a osteomielite crônica recorrente multifocal é um dos diagnósticos diferenciais das espondilites infecciosas. Seu reconhecimento pode evitar tratamentos antimicrobianos prolongados e desnecessários