Errors on dilution of intravenous medication in a hospital, and development of a drug dilution and administration guide

Abstract

The adverse events from medication are all kind of damage caused to patients, that can lead to significant harm to health, with relevant economic and social consequences, which is considered a public health problem. The medication errors, as an adverse event, can be avoided. On a hospital environment, errors on medication are a responsibility of the nursing team, due to its direct relation to the patient. Previous studies have shown that the frequency of the errors varies from one to six doses given, with different justifications. The study aimed to identify the errors frequency on the dilution of intravenous medication
process, to propose an action that helps its reduction. The data research was made in October 2014, typified as a transversal descriptive research, with an observation nature. During this period, the activities of 18 nursing technicians involved in the intravenous medication preparation and administration, who worked in Intensive Therapy Units, were observed. 180 doses were verified, from which 125 (69.5%) presented at least one dilution error. In 90 doses, (72%) it was noticed more than one error per dose, and no evaluation or report of the medication errors was made. It was noticed that the professionals involved with the errors did not know how to identify them, and such event may compromise the effectiveness of the treatment. Also, the medications with a higher frequency of dilution errors were identified. Therefore, other diluents were defined, according to specific literature. This outcome turned into an educational material, as a file, to be quickly consulted.