ABSTRACTS

Drug Safety 2008; 31 (10): 885-960 0114-5916/08/0010-0885/$48.00/0 © 2008 Adis Data Information BV. All rights reserved.

179 Assessment of Medication Error Reports Sent to Brazilian Medicine Monitoring Centre (CNMM) Bittencourt MO,(1) Luiz SCC,(1) Silva LAM,(1) Santos AS,(1) Teixeira CS,(1) Souza NR,(1) Dias MF(1) (1)Brazilian Health Surveillance Agency (Anvisa), Brasilia, DF, Brazil Background: Medication error reporting system was first made available on Anvisa’s website in 2005, primarily for testing the new form. In April 2007, the final form was highly disseminated by publishing the Technical Inform n. 2 and sending a circulating letter for health professional associations, sentinel hospital net, local health surveillance coordinations, among others. The forms are available in both electronic and PDF at http:// www.anvisa.gov.br/servicos/form/farmaco/index_prof_erro.htm. Objective: To describe medication error reports sent to Brazilian Medicine Monitoring centre (CNMM) from December 2005 to April 2008. Methods: Medication error reports were assessed according to reporter institution and professional categories, therapeutic class (ATC classification) involved, therapeutic chain step where the error started (e.g. prescription, dispensing/distribution, preparing, administration), mainly cause of the error and where it occurred (e.g. hospital, pharmacy, health clinic, patient’s home). Results: From December 2005 to April 2008, CNMM received 141 medication error reports. Most of the assessed reporting forms (24,8%) were sent by sentinel hospitals, and the pharmacists were the professional who reported more (48,2%). The therapeutic classes frequently present in the reports were antibacterials for systemic use (18,4%), analgesics (10,6%), agents acting on the renin-angiotensin system (6,4%) and psycholeptics (6,4%). Drug administration (42,7%), prescription (30,1%) and dispensing (16,8%) were the most common therapeutic chain steps where the errors started. The following error causes were most reported: distraction (31,4%), illegible prescription or its lack of information (24,2%), and administration routine (22,9%). Hospitals were the place where the errors occurred more (63,4%). It is expected since hospitals have reported more than other institutions. Conclusion: Considering the results achieved, Brazilian medication error reporting system is providing good information about why, when, how and where the errors can occur. This information will be useful to develop strategies for preventing these events and promoting patient safety. Conflicts of interest: None declared.