Clinical Risk Management and reporting of medication errors

Abstract

BACKGROUND:
Nurses are primarily responsible for administering therapy. The prevention of errors represent a fundamental moment of the care process. Risk Management has developed procedures to prevent adverse events. Spontaneous reporting of events is not widespread in health care such as using clinical risk tools.

AIMS:
To detect what are the gaps or difficulties encountered in the reporting of adverse events, during the management of drug therapy.

METHODS:
Single-center quantitative study in medical and surgical departments. A questionnaire was used.

RESULTS:
A total of 103 questionnaires were considered. Almost all of the sample is familiar with the scope of Clinical Risk Management, providing a fair definition. More than half of the sample (n=67, 65%) report that they have incurred a medication error or near miss during their work career. Thirty-nine nurses (38%) used the Incident Reporting Form available in the Operating Unit, while sixty-four (62%) orally reported events that occurred directly to the nursing coordinator, physician, or colleague; those who did not use the Incident Reporting tool stated that they never reported errors.

CONCLUSIONS:
Nurses in the survey context recognize the importance of clinical risk management through the use of procedures and Incident Reporting Form. However, more than half of the sample report that they do not use it for reporting medication errors and near misses. The barriers to reporting suggest the need to strengthen awareness of the tool and to promote improvements in organizational climate through the promotion of transparency between professionals.