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1.
Radiol Clin North Am ; 58(5): 841-850, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32792118

RESUMO

Moderate and severe contrast reactions are rare but can be life threatening. Appropriate contrast reaction management is necessary for the best patient outcome. This review summarizes the types and incidences of adverse events to contrast media, treatment algorithms, and equipment needed to treat common contrast reactions, the current status of contrast reaction management training, and preventative strategies to help mitigate adverse contrast events.


Assuntos
Meios de Contraste/efeitos adversos , Hipersensibilidade a Drogas/diagnóstico , Extravasamento de Materiais Terapêuticos e Diagnósticos/prevenção & controle , Gadolínio/efeitos adversos , Iodo/efeitos adversos , Radiologia/educação , Humanos , Erros de Medicação/prevenção & controle , Fatores de Risco
3.
Stud Health Technol Inform ; 272: 470-473, 2020 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-32604704

RESUMO

Clinical Decision Support Systems (CDSSs) are used in a clinical setting to help physicians make decisions to improve clinical performance and patient care. There are many benefits to the implementation and adoption of CDSSs, such as reducing the rate of misdiagnosis, improving efficiency and patient care, and reducing the risk of medication errors. On the other hand, CDSSs can have several disadvantages. For example, physicians can see CDSSs as a threat to their clinical autonomy. CDSSs can also be very costly to adopt, maintain, and support. These advantages and disadvantages can have both positive and negative impacts on physicians. We conducted a scoping review to explore the impact of CDSSs on physicians. We searched the following electronic databases: CINAHL, PubMed, and Google Scholar. Two reviewers independently selected the retrieved studies and extracted data from the included studies. A narrative approach was used to synthesize the extracted data. We included 14 studies of the 300 retrieved studies. We identified the following positive impacts: work efficiency, providing more personalized care, improving care and knowledge, increasing confidence in making decisions, improving prescribing behavior, and reducing the number of ordered laboratory and medical imaging tests. Several negative impacts were also reported by the studies, namely: inefficient documentation, interruption in the patient-physician communication, and an increase in unnecessary referrals.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Médicos , Tomada de Decisões , Humanos , Erros de Medicação
4.
Rev Infirm ; 69(260-261): 41-43, 2020.
Artigo em Francês | MEDLINE | ID: mdl-32600597

RESUMO

Nurses are regularly interrupted when performing their tasks. Yet studies have shown that there is a link between the fact of being interrupted when preparing medication and the increased risk of making a mistake. Seeking to reinforce the safety of the medication preparation stage, a team in Normandy studied the benefit, for the nurse, of wearing ear plugs during this specific time.


Assuntos
Atenção , Erros de Medicação/prevenção & controle , Enfermeiras e Enfermeiros/psicologia , Gestão da Segurança/métodos , França , Humanos
5.
Stud Health Technol Inform ; 272: 63-66, 2020 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-32604601

RESUMO

Adverse events (AEs) in healthcare are commonly reported internationally. However, the structure of event reporting varies based on the healthcare service system, legislation, and the safety culture among service providers. Based on several studies, medication management-related errors have a long history of being reported. However, there is evidence that information management-related errors increase workload, costs, and patient suffering. This study focuses on AEs reported in the categories of medication and information management in a national reporting system. Our aim was to determine whether patients were informed about these errors and whether there were any relationships between the severity of these errors and the disclosure to patients. Based on the results, almost all errors in both categories without any harm to patients were disclosed to patients. Patients were not informed about 40% of information management-related AEs that caused severe harm.


Assuntos
Gestão da Segurança , Conscientização , Humanos , Erros de Medicação , Gestão de Riscos
6.
Yakugaku Zasshi ; 140(10): 1285-1294, 2020 Oct 01.
Artigo em Japonês | MEDLINE | ID: mdl-32611936

RESUMO

Care workers at care facilities play an important role in providing medication-administration assistance, and in medication risk management. Nevertheless, research has not made clear the specific concerns that care workers have at work sites, as well as the extent of their burdens. Thus, we conducted a questionnaire survey from October 1 through October 31, 2014 for staff who provide medication-administration assistance at for-pay elderly person homes about the concrete concerns and burdens with regards to the assistance. A total of 1677 respondents were analyzed: 228 nurses and 1449 care workers. Results showed that the care workers had a variety of problems and issues. These included the fact that, since care workers are not medical profession, they were unable to answer questions that the facility residents asked about their medications; they had concerns regarding their own lack of awareness of the efficacies of medications, and as to whether certain drugs were inappropriate for certain patients with swallowing dysfunctions; they wondered whether drugs in tablet forms had to be crushed before administration. They also encountered pharmacological-related issues, including whether administration times and numbers failed to match the lifestyle patterns of facility residents, and so forth. It is presumed that, with active intervention of pharmacists within facilities, these issues could be resolved. Study results, thus, suggested the need for system creation whereby pharmacists can become deeply involved in medication-administration assistance along with the care workers within facilities.


Assuntos
Atitude do Pessoal de Saúde , Erros de Medicação/prevenção & controle , Casas de Saúde , Recursos Humanos de Enfermagem/psicologia , Farmacêuticos , Gestão de Riscos , Adulto , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Adulto Jovem
8.
Stud Health Technol Inform ; 270: 1267-1268, 2020 Jun 16.
Artigo em Inglês | MEDLINE | ID: mdl-32570612

RESUMO

The purpose of this study is to describe nurses' views of what supports safe medication administration in the current electronic medication administration system. Data was collected at the turn of 2014-2015 and open-ended answers were inductively analyzed using content analysis. The system's usefulness, good usability, and the feature that there is extra information available on medications and the patient-specific information needed in medication administration are elements that support safe medication administration. The study identifies wide support for the electronic medication administration system in safe medication administration.


Assuntos
Sistemas de Medicação , Erros de Medicação
9.
Stud Health Technol Inform ; 270: 1271-1272, 2020 Jun 16.
Artigo em Inglês | MEDLINE | ID: mdl-32570614

RESUMO

Chemotherapy drugs are one of the most common causes of serious and fatal medication errors, especially during prescribing, where computerized physician order entry (CPOE) take on importance. This study proposes the description of the post-implementation status of a CPOE in a highly specialized hospital between January and June 2018, among patients older than 18 years. Results: a total of 8835 protocols were indicated using the specific CPOE (93% use rate over all protocols) 91% completed the administration, 1.2% were rejected by pharmacy, and 6.8% was canceled. The most frequent cause of rejection by pharmacy and cancellation by oncologist was an inadequate dose. Most of the protocols indicated using the CPOE implemented, with a reject by pharmacy rate of 1.2%, indicates the utility of CPOE as an error prevention strategy.


Assuntos
Protocolos Antineoplásicos , Sistemas de Registro de Ordens Médicas , Antineoplásicos , Erros de Medicação
10.
Stud Health Technol Inform ; 270: 1036-1040, 2020 Jun 16.
Artigo em Inglês | MEDLINE | ID: mdl-32570539

RESUMO

Health information systems (HIS) and clinical workflows generate medication errors that affect the quality of patient care. The rigorous evaluation of the medication process's error risk, control, and impact on clinical practice enable the understanding of latent and active factors that contribute to HIS-induced errors. This paper reports the preliminary findings of an evaluation case study of a 1000-bed Japanese secondary care teaching hospital using observation, interview, and document analysis methods. Findings were analysed from a process perspective by adopting a recently introduced framework known as Human, Organisation, Process, and Technology-fit. Process factors influencing risk in medication errors include template- and calendar-based systems, intuitive design, barcode check, ease of use, alert, policy, systematic task organisation, and safety culture Approaches for managing medication errors also exert an important role on error reduction and clinical workflow.


Assuntos
Sistemas de Informação em Saúde , Processamento Eletrônico de Dados , Humanos , Erros de Medicação , Sistemas de Medicação no Hospital , Fluxo de Trabalho
11.
PLoS One ; 15(6): e0233486, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32497110

RESUMO

BACKGROUND: Most residents in elderly care homes in Sri Lanka do not receive formal, on-site, patient care services. OBJECTIVE: To evaluate the appropriateness of prescribing, dispensing, administration, and storage practices of medication used by residents in selected elderly care homes in Colombo District, Sri Lanka. METHODOLOGY: This was a prospective, cross-sectional, multi-center study of 100 residents with chronic, non-communicable diseases, who resided in nine selected elderly care homes in Sri Lanka. Medication histories were obtained from each resident/caregiver and the appropriateness of medications in their current prescription was reviewed using standard treatment guidelines. Prescriptions were cross-checked against respective dispensing labels to identify dispensing errors. Medication administration was directly observed on two separate occasions per resident for accuracy of administration, and matched against the relevant prescription instructions. Medication storage was also observed in terms of exposure to temperature and sunlight, the suitability of container, and adequacy of separation if using multiple medications. RESULTS: The mean age of residents was 70±10.5 years and the majority were women (72%). A total of 168 errors out of 446 prescriptions were identified. The mean number of prescribing errors per resident was 1.68±1.23 [median, 2.00 (1.00-3.00)]. Inappropriate dosing frequencies were the highest (37.5%;63/168), followed by missing or inappropriate medications (31.5%;53/168). The mean number of dispensing errors per resident was 15.9±13.1 [median, 14.0 (6.00-22.75)] with 3.6 dispensing errors per every medication dispensed. Mean administration errors per resident was 0.95±1.5 [median, 0.00 (0.00-1.00)], with medication omissions being the predominant error (50.5%;48/95). Another lapse was incorrect storage of medications (143 storage errors), and included 83 medications not properly separated from each other (58.0%). CONCLUSION: Multiple errors related to prescribing, dispensing, administration, and storage were identified amongst those using medication in elderly care homes. Services of a dedicated consultant pharmacist could improve the quality of medication use in elderly care homes in Sri Lanka.


Assuntos
Erros de Medicação/estatística & dados numéricos , Conduta do Tratamento Medicamentoso , Casas de Saúde , Segurança do Paciente , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Interações Medicamentosas , Armazenamento de Medicamentos , Feminino , Humanos , Prescrição Inadequada , Masculino , Sistemas de Medicação/organização & administração , Sistemas de Medicação/estatística & dados numéricos , Conduta do Tratamento Medicamentoso/organização & administração , Conduta do Tratamento Medicamentoso/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos Prospectivos , Garantia da Qualidade dos Cuidados de Saúde , Sri Lanka
12.
Epidemiol Health ; 42: e2020030, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32512668

RESUMO

OBJECTIVES: Medication errors (MEs) made by nurses are the most common errors in emergency departments (EDs). Identifying the factors responsible for MEs is crucial in designing optimal strategies for reducing such occurrences. The present study aimed to review the literature describing the prevalence and factors affecting MEs among emergency ward nurses in Iran. METHODS: We searched electronic databases, including the Scientific Information Database, PubMed, Cochrane Library, Web of Science, Scopus, and Google Scholar, for scientific studies conducted among emergency ward nurses in Iran. The studies were restricted to full-text, peer-reviewed studies published from inception to December 2019, in the Persian and English languages, that evaluated MEs among emergency ward nurses in Iran. RESULTS: Eight studies met the inclusion criteria. Most of the nurses (58.9%) had committed MEs only once. The overall mean rate of MEs was 46.2%, and errors made during drug administration accounted for 41.7% of MEs. The most common type of administration error was drug omission (17.8%), followed by administering drugs at the wrong time (17.5%) and at an incorrect dosage (10.6%). The lack of an adequate nursing workforce during shifts and improper nurse-patient ratios were the most critical factors affecting the occurrence of MEs by nurses. CONCLUSIONS: Despite the increased attention on patient safety in Iran, MEs by nurses remain a significant concern in EDs. Therefore, nurse managers and policy-makers must take adequate measures to reduce the incidence of MEs and their potential negative consequences.


Assuntos
Enfermagem em Emergência , Serviço Hospitalar de Emergência , Erros de Medicação/estatística & dados numéricos , Humanos , Irã (Geográfico)
13.
Stud Health Technol Inform ; 270: 683-687, 2020 Jun 16.
Artigo em Inglês | MEDLINE | ID: mdl-32570470

RESUMO

Clinical decision support systems (CDSS) fail to prevent adverse drug events (ADE), notably due to over-alerting and alert-fatigue. Many methods have been proposed in the literature to reduce over-alerting of CDSS: enhancing post-alert medical management, taking into account user-related context, patient-related context and temporal aspects, improving medical relevance of alerts, filtering or tiering alerts on the basis of their strength of evidence, their severity, their override rate, or the probability of outcome. This paper analyzes the different options, and proposes the setup of SPC-CDSS (statistically prioritized and contextualized CDSS). The principle is that, when a SPC-CDSS is implemented in a medical unit, it first reuses actual clinical data, and searches for traceable outcomes. Then, for each rule trying to prevent this outcome, the SPC-CDSS automatically estimates the conditional probability of outcome knowing that the conditions of the rule are met, by retrospective secondary use of data. The alert can be turned off below a chosen probability threshold. This probability computation can be performed in each medical unit, in order to take into account its sensitivity to context.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Humanos , Sistemas de Registro de Ordens Médicas , Erros de Medicação , Estudos Retrospectivos
14.
Stud Health Technol Inform ; 270: 906-910, 2020 Jun 16.
Artigo em Inglês | MEDLINE | ID: mdl-32570513

RESUMO

Clinical decision support systems (CDSSs) provides vital information for managing patients by advising clinicians through an alert or reminders about adverse events and medication errors. Clinicians receive a high number of alerts, resulting in alert override and workflow disruptions. A systematic review was carried out to identify factors affecting CDSS alert appropriateness in supporting clinical workflows using a recently introduced framework. The review findings identified several influencing factors of CDSS alert appropriateness including: technology (usability, alert presentation, workload and data entry), human (training, knowledge and skills, attitude and behavior), organization (rules and regulation, privacy and security) and process (waste, delay, tuning and optimization). The findings can be used to guide the design of CDSS alert and minimise potential safety hazards associated with CDSS use.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Sistemas de Registro de Ordens Médicas , Humanos , Erros de Medicação , Fluxo de Trabalho
15.
Emergencias (Sant Vicenç dels Horts) ; 32(3): 188-190, jun. 2020. tab
Artigo em Espanhol | IBECS | ID: ibc-189732

RESUMO

OBJETIVOS: Analizar la gravedad de los errores de conciliación (EC) producidos en el servicio de urgencias (SU) en pacientes que ingresan en una unidad de agudos de geriatría. Cuantificar y describir las discrepancias y los EC. Analizar los grupos farmacológicos y los factores de riesgo. MÉTODO: Estudio observacional prospectivo. Un farmacéutico realizó la historia farmacoterapéutica y comparó el tratamiento habitual con el prescrito en el SU, identificó discrepancias y posibles EC y un geriatra evaluó su gravedad. RESULTADOS: Se incluyeron 351 pacientes, de los que 328 (93,8%) presentaron discrepancias, 151 pacientes (43,02%) presentaron al menos 1 EC. Se observaron 300 EC de los que 248 (82,7%) alcanzaron al paciente, y 27 EC (9%) produjeron daño reversible. No hubo ningún error que causase daño prolongado o mortal. CONCLUSIONES: Los EC fueron frecuentes pero de escasa gravedad, y los daños que ocasionaron fueron reversibles


OBJECTIVES: To analyze the seriousness of medication reconciliation errors (MREs) in the treatment of older patients admitted to an emergency department's acute geriatric unit. To identify and describe discrepancies, including the drug groups involved, and to explore risk factors. METHODS: Prospective, observational 6-month study. A pharmacist recorded medications in each patient's history and compared the patient's usual treatment to the regimen prescribed in the emergency department; discrepancies were flagged for evaluation as possible MREs. A geriatric medicine specialist evaluated MRE seriousness. RESULTS: Three hundred twenty-eight discrepancies were detected (93.8% of the total of 351 patients); 151 patients (43.02%) had at least 1 MRE. Three hundred MREs were identified, 248 (82.7%) reached the patient, and 27 (9%) caused reversible injury. No errors led to prolonged injury or death. CONCLUSIONS: MREs were common but not serious, and the injuries caused were reversible


Assuntos
Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Reconciliação de Medicamentos , Fatores de Risco , Erros de Medicação/classificação , Estudos Prospectivos , Intervalos de Confiança , Polimedicação
16.
Farm. hosp ; 44(3): 114-121, mayo-jun. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-192344

RESUMO

INTRODUCCIÓN: La tecnología sanitaria se ha convertido en la solución más aceptada para reducir los eventos adversos provocados por los medicamentos, minimizando los posibles errores humanos. La introducción de la tecnología puede mejorar la seguridad y permitir una mayor eficiencia en la clínica. Sin embargo, no elimina todos los tipos de error y puede crear otros nuevos. La administración de medicamentos con código de barras y la utilización de bombas de infusión inteligentes son dos estrategias que pueden emplearse durante la administración de medicamentos para evitar errores antes de que estos lleguen al paciente. OBJETIVO: En este artículo se han revisado diferentes tipos de errores relativos a la administración de medicamentos con código de barras y las bombas de infusión inteligentes, y se ha examinado la forma en la que se producían dichos errores al emplear la tecnología. También se exponen las recomendaciones encaminadas a evitar este tipo de errores. CONCLUSIÓN: Los hospitales deben comprender la tecnología, su funcionamiento y los errores que pretende evitar, así como analizar de qué manera cambiará los procesos clínicos. Es esencial que la dirección del hospital establezca las métricas necesarias y las monitorice regularmente para garantizar el uso óptimo de estas tecnologías. También es importante identificar y evitar desviaciones en los procesos que puedan eliminar o disminuir los beneficios de seguridad para los que fue diseñada. De igual forma, es necesario recopilar periódicamente las opiniones del profesional que la utiliza para detectar los posibles problemas que pudieran surgir. Sin embargo, la dirección debe ser consciente de que incluso con la implementación completa de la tecnología pueden surgir errores a la hora de administrar la medicación


INTRODUCTION: Healthcare-related technology has been widely accepted as a key patient safety solution to reduce adverse drug events by decreasing the risk of human error. The introduction of technology can enhance safety and support workflow; however, it does not eliminate all error types and may create new ones. Barcode medication adminis-tration and smart infusion pumps are two technologies utilized during medication administration to prevent medication errors before they reach the patient. OBJECTIVE: This article reviewed different error types with barcode medi-cation administration and smart infusion pumps and examined how these errors were able to occur while using the technology. Recommendations for preventing these types of errors were also discussed. CONCLUSION: Hospitals must understand the technology, how it is desig-ned to work, which errors it is intended to prevent, as well as understand how it will change staff workflow. It is essential that metrics are set by hospital leadership and regularly monitored to ensure optimal use of these technologies. It is also important to identify and avoid workarounds which eliminate or diminish the safety benefits that the technology was designed to achieve. Front line staff feedback should be gathered on a periodic basis to understand any struggles with utilizing the technology. Leaders must also understand that even with full implementation of technology, medication errors may still occur


Assuntos
Humanos , Erros de Medicação/prevenção & controle , Preparações Farmacêuticas/administração & dosagem , Processamento Eletrônico de Dados/métodos , Bombas de Infusão , Gestão da Segurança/métodos , Acesso a Medicamentos Essenciais e Tecnologias em Saúde , Quimioterapia Assistida por Computador/métodos
17.
Clin Drug Investig ; 40(8): 687-693, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32514939

RESUMO

Patient harm from inadvertent administration of amphotericin B (Fungizone™) instead of liposomal amphotericin (AmBisome®) has been described in the literature and has been the subject of patient safety alerts in the UK. Safe use of intravenous amphotericin depends on the knowledge and awareness of practitioners of the availability and differences between the different presentations of intravenous amphotericin. Knowledge is a weak barrier to error. Recommendations to reduce the risk of error following adverse drug events in the UK, USA and The Netherlands have largely focused on actions to be taken at an organisational level, such as drug supply, storage, dose checking and specifying brand and generic names on prescriptions. None have considered or addressed the contributory factors relating to the products themselves, namely the similarity between the presentations of AmBisome and Fungizone, both of which are manufactured as 50 mg vials despite their different dose recommendations. The need to use multiple vials of Ambisome to prepare infusions for adult patients is contrary to the usual practice of using only one or two vials to prepare doses of injectable medicines for adult patients, increasing the risk of error not only with injectable amphotericin formulations but potentially also with the preparation of other injectable medicines. Whilst the development of robust local risk reduction strategies are important, external factors, such as the design of medicines, should also be identified and highlighted to manufacturers and regulatory authorities as potential contributors to error and harm.


Assuntos
Anfotericina B/efeitos adversos , Antifúngicos/efeitos adversos , Anfotericina B/administração & dosagem , Antifúngicos/administração & dosagem , Composição de Medicamentos , Humanos , Erros de Medicação/prevenção & controle
18.
Ceska Slov Farm ; 69(2): 100-102, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32545989

RESUMO

Case (description): A 74 years old Caucasian suffering from chronic kidney disease presented with progressive asthenia and diffuse myalgia. It was revealed that the patient used three different rosuvastatin-containing preparations in a total daily dose of 120 mg for 76 days. Laboratory investigations revealed a marked elevation of serum urea, creatinine, myoglobin, creatine kinase (CK) and transaminases. Two serious medication errors have been identified as possible major factors that synergistically contributed to the development of rosuvastatin-induced rhabdomyolysis. First, 40 mg of rosuvastatin dose was prescribed to the patient, although the estimation of glomerular filtration rate (eGFR) declined below 40 ml/min/1.73 m2. Moreover, the patient used 3 different rosuvastatin formulations simultaneously in a total dose of 120 mg/day. The heterozygous CYP2C9*1/*3 genotype and warfarin co-administration could further contribute to the development of rhabdomyolysis. A number of preventive measures, notably in drug policy, are suggested to overcome unintended intoxications. Conclusion: Rosuvastatin-induced myopathy is a rare, but serious adverse effect. This case report highlights the need for a proper treatment and dose adjustment during chronic medical therapy, the need for adequate patient education and application of adequate drug policy measures in the era of fragmented health care delivery and polypragmasia.


Assuntos
Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Erros de Medicação , Rabdomiólise/induzido quimicamente , Rosuvastatina Cálcica/efeitos adversos , Idoso , Humanos
20.
Anesthesiology ; 133(2): 332-341, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32541549

RESUMO

BACKGROUND: While 4 to 10% of medications administered in the operating room may involve an error, few investigations have prospectively modeled how these errors might occur. Systems theoretic process analysis is a prospective risk analysis technique that uses systems theory to identify hazards. The purpose of this study was to demonstrate the use of systems theoretic process analysis in a healthcare organization to prospectively identify causal factors for medication errors in the operating room. METHODS: The authors completed a systems theoretic process analysis for the medication use process in the operating room at their institution. First, the authors defined medication-related accidents (adverse medication events) and hazards and created a hierarchical control structure (a schematic representation of the operating room medication use system). Then the authors analyzed this structure for unsafe control actions and causal scenarios that could lead to medication errors, incorporating input from surgeons, anesthesiologists, and pharmacists. The authors studied the entire medication use process, including requesting medications, dispensing, preparing, administering, documenting, and monitoring patients for the effects. Results were reported using descriptive statistics. RESULTS: The hierarchical control structure involved three tiers of controllers: perioperative leadership; management of patient care by the attending anesthesiologist, surgeon, and pharmacist; and execution of patient care by the anesthesia clinician in the operating room. The authors identified 66 unsafe control actions linked to 342 causal scenarios that could lead to medication errors. Eighty-two (24.0%) scenarios came from perioperative leadership, 103 (30.1%) from management of patient care, and 157 (45.9%) from execution of patient care. CONCLUSIONS: In this study, the authors demonstrated the use of systems theoretic process analysis to describe potential causes of errors in the medication use process in the operating room. Causal scenarios were linked to controllers ranging from the frontline providers up to the highest levels of perioperative management. Systems theoretic process analysis is uniquely able to analyze management and leadership impacts on the system, making it useful for guiding quality improvement initiatives.


Assuntos
Anestesiologia/normas , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Erros de Medicação/prevenção & controle , Salas Cirúrgicas/normas , Melhoria de Qualidade/normas , Teoria de Sistemas , Anestesiologistas/normas , Humanos , Salas Cirúrgicas/métodos , Farmacêuticos/normas , Estudos Prospectivos , Cirurgiões/normas
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