Causas e fatores subjacentes de erros de prescrição na perspectiva de médicos seniores

Abstract

In the hospital setting, medication errors are common at all stages of the process (acquisition, dispensing, prescription, administration, and monitoring the patient's response), but those occurring during the prescription process are the most serious in terms of harm to patients. This study investigated medication prescription errors, their causes, and underlying factors, from the perspective of senior doctors at a Brazilian university hospital. It is a qualitative study, with data collected through individual interviews using a semi-structured script and questions related to the planning and execution of prescriptions. Interviews were conducted with 19 senior doctors. The data were organized with the help of Nvivo© software, and the prescription errors were counted. Otero-López’s taxonomy was used to categorize the types of errors reported. The data were analyzed according to Reason’s Accident Causality Model, and active failures were classified into slips, lapses, and violations. Latent conditions and error-producing factors were also examined for each type of active failure. Questions about the nature of the errors, the situation in which they occurred, influencing factors, and feelings and attitudes as a result of them were addressed. A total of 42 prescription errors were reported. The main type of error was incorrect dosage. Most of the recorded active failures were slips, knowledge-based errors, and violations. The main error-producing conditions were related to the electronic prescription system and the lack of prescription checks. Time pressure during prescription and workload overload were the main environmental factors that led to the occurrence of prescription errors. According to the interviewees, no specific training regarding prescription was received during medical school or residency. Feelings of guilt were expressed by participants after becoming aware of a prescription error. Gratitude was described when an error was intercepted before affecting the patient. The participants also reported that after experiencing an error, strategies such as prior planning, checking printed prescriptions, and external assistance were developed to prevent further errors. The results highlighted the nature and severity of prescription errors in hospital settings and indicated that the causes are multifactorial. Interventions should be implemented to improve patient safety and the safety of professionals involved in the medication use process.