Safety in the Preparation and Administration of Medication

Implementation of a Patient Safety Project

Abstract

Introduction: Incidents can occur at any stage of the medication circuit. Preparation and administration are critical moments, as the occurrence of an error can lead to serious consequences for the patient. An independent double-check is a complementary safety strategy that involves the verification of medication by two professionals at different times.

Objective/s: Increase safety in the preparation and administration of medication for hospitalized patients. Specific objectives: Identify incidents in medication preparation; Implement strategies that promote the safe use of medication.

Methods:  An experience report on the development of a continuous improvement and patient safety project in a Portuguese hospital inpatient unit, focusing on the safety in the preparation and administration of medication. Verification was implemented and carried out by two nurses during the preparation of medication, with near-miss events identified and recorded anonymously and voluntarily by the nurses.

Results: The implementation process of this strategy was developed in three phases. The most frequent near-miss events were related to omission in the dispensing of the unit dose; incorrect dosage (including high-alert medication); incorrect timing, and medication swap.

Conclusion: Double-check of medication allowed for the identification and correction of near-miss events, proving to be a good practice to promote patient safety.