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Consulting about medication error in SERTOX, 1990-1997

2 October, 2004

J. C. Piola (*); D.B. Prada (*); M. Evangelista (*). Rev Med Rosario 65 (1);1999, 7-12.

(*) Servicio de Toxicología del Sanatorio de Niños, Rosario

Medication error (ME) constituted an interesting group of accidental poisonings that were assisted by us between 1990 and 1997. The problems and sources of ME are multidisciplinary and multifactorial. Pharmacists, physicians, nurses, supportive personnel (e.g., pharmacy technicians), patients and their caregivers and others may make ME. This work presents the data of 37O patients with ME that were assisted in Servicio de Toxicología del Sanatorio de Niños (SERTOX) between January 1990 and December 1997. The patients age was in the range of O-2O years in 73% of cases. 68.8% of patients under 20 years were male and 60% of over 20 years patients were female. The consultation was more frequent during Monday, Tuesday, Friday and Sunday. The months May, June, July and September had more ME consults; the annual ME consultation average 3.6%; 36.8% occurred between 8AM and 14 PM; 16.3% between 14 PM and 18 PM and 34.5% between 18 PM and 24 PM. 64.5% of the ME consultation were made during the hour immediately afterwards it happened.
The types of EM considered by us were: prescribing error (7), unauthorised drug error (122)or use of a non medicament instead of prescribed medicament (55), not preescribed doses (142), extra doses (14), the way and/or the celerity of administration (39), expired medicament (1). Sometimes they could be classified on 2 or more categories because they do not exclude each other. The 84.9% of ME were with medicaments and the 15.1 were with non-medicaments. The more frequent ME were with the following medicameuts: autonomic nervous systems acting Z3.3%); external use (22%); non-classified by CIE (13.4%) and antibiotics.The more frequent non-medication ME was with hypoclorite and others caustics (39.3%), organophosphorus anticholinesterase insecticides and others (25%). The absorption routes were: ingestion (81.3%); mucous (8.1%); intravenous, intramuscular and subcutaneus (6.8%); inhalation (2.2%) and dermatological (1.6%). 61.2% were asymptomatic patients, 30.2% were with light symptomatology. Three patients had severe symptomatology. Two patients died. More frequent symptomatologies were neurological (36. 1%); gastroenterological (22.2%) and others symptoms (20.8%).
There are not any data available about ME in our country. We think that collecting data is the first step to identify the causes and prevent them. The real solutions would be interdisciplinary. We are trying to improve our knowledge about ME in Rosario and our region, to adapt the assistance to this reality and prevent this type of accidents. ME should be reported to a national monitorhtg program like Medication Errors Reporting Program of USA.

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