[Root cause analysis: evaluation of medication errors at a university hospital]. / Análise de causa raiz: avaliação de erros de medicação em um Hospital Universitário.

The objectives of this study were to identify and analyze the types of medication errors observed in doses prepared and administered differently from those prescribed. It is a descriptive study using the root cause analysis method, in which a secondary analysis of data from a previously existing investigation was performed. In the study, 74 medication errors were identified during medication preparation and administration by the nursing staff. Dose errors (24.3%), schedule errors (22.9%) and unauthorized medication administration errors (13.5%) were the most frequent. Hence, medication errors were identified, and root cause analysis was performed, leading to the identification of multiple factors that contributed to error occurrence. Strategies and recommendations were presented for the prevention of errors.

[Medication errors: types, causes and measures taken in four Brazilian hospitals]. / Erros de medicação: tipos, fatores causais e providênclas tomadas em quatro hospitais brasileiros.

This study analyzed the causes, types, administrative measures taken and suggestions concerning medication errors according to the perspective of professionals involved with the medication systems in four Brazilian hospitals. It is an exploratory, survey-type, multicentric study. The sample consisted of professionals from the medical clinic and pharmacy in the above-mentioned hospitals. Semistructured interviews were used for data collection. Results showed that the most frequently error types mentioned by the professionals were related to medication ordering/transcription. Lack of attention, individual mistakes and problems in service management were the major causes of errors. Reports were the main measures taken in view of errors, and changes in individual attitudes were the most frequently mentioned form to prevent them.

[Strategies for prevention of medication errors in emergengy services]. / Estratégias para prevenção de erros de medicaçã n o Setor Emergência.

This study identified situations indicating medication errors or near misses by analyzing medication orders and the nursing staff's performance. It also implemented a cycle of lectures and a course on safety in medication administration for professionals at the emergency room in a hospital in the northeastern region of Brazil. The results showed that of 1,585 orders under analysis, 83,9% did not clearly express the medication presentation and 84.6% did not define the dosage from prescribed medication, in 34.2%, the administration time was unchecked; in 22.5%, the time had been circled. Among the non-administered medication, 26% were antibiotics and anticoagulants and 15% analgesics. The professionals participated in the implemented strategies with good attendance levels.