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Introduction: There is increasing data collection in literature on errors in the drug
administration chain. In anesthesiology, emergency and urgency situations favor
errors in medications, however, it is not yet clear how some factors can impact the
frequency of these errors.
Objective: To evaluate the impact of knowledge of important concepts and
fundamentals related to quality and safety in anesthesia in the practice of safe
anesthesia as a factor to prevent errors with medications.
Method: Observational study with participants of the 61st Brazilian Congress of
Anesthesia. The volunteers responded to a semi-structured instrument with issues
related to the whole process that could trigger medication errors.
Results: A total of 337 volunteers (42.2% of Anesthesia Resident Physicians and
57.8% of Anesthesiologists) participated in the study. It was observed that 50.7%
stated that eventually they had already injected wrong medications, with a significant
difference (p <0.00) between the Anesthesia Resident Physicians (43.6%) and
Anesthesiologists (56%). A greater number of working hours and greater number of
hospitals in which they work caused higher percentages of professionals with
medication errors. Among the professionals who reported they had eventually
administered erroneous medications due to confusion with ampoules , 33.8% (n = 54)
of those stated that they made a formal report of the adverse event with medications
(ARP: 24.1% and MA: 39,2%). 96.9% (n = 155) found ampules of different
medications (or concentrations thereof) in the same drug box (ARP) : 93.1%, MA:
99%) and 65.2% stated they have used the same syringe to prepare more than one
anesthetic medication (ARP 75.9%, MA: 59%).
Conclusions: The percentage of medication errors was significant and it is evident
the need to implement policies that will guide the organization, distribution, allocation
and use of medications in the surgical center.
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