Medical errors in medication prescriptions

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REVIEW ARTICLE

SAVIAN, Tiago Rezende [1], FRAGA, Carolina Cândida De Resende [2], FRAGA, Ana Laísa Cândida De Resende [3]

SAVIAN, Tiago Rezende. FRAGA, Carolina Cândida De Resende. FRAGA, Ana Laísa Cândida De Resende. Medical errors in medication prescriptions. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 05, Ed. 01, Vol. 04, pp. 46-61. January 2020. ISSN: 2448-0959, Acess Link: https://www.nucleodoconhecimento.com.br/health/medical-errors

SUMMARY

Medical error occurs when a healthcare professional chooses an inadequate method of care or improperly performs a correct method. They are often described as human errors in the area of health. However, definitions of medical error are subject to debate, as there are many types of medical errors, from minor to greater severity, and causality is often poorly determined. The aim of this review study was to demystify medical errors, with a primary focus on drug prescription, identifying the errors and risks that the citizen/patient can be affected taking into account the lack of readability, and what can be done to minimize these errors. It was concluded, from an ethical point of view, that both areas are making mistakes, either in the prescription of prescriptions or during interpretation, being indispensable the supervision of all medical prescriptions.

Keywords: Medical prescriptions, medical errors, medication errors.

1. INTRODUCTION

Prescriptions are often the subject of speculation, but nothing that can be led to any change for the benefit of society. The term “doctor’s letter” is an ancient jargon, and by the current visa. In the past, not so remote, families had their family doctors who went to the house to prescribe treatment to the patient, and he did not worry about what the doctor had prescribed. But today, with all the technological advances and virtual information, this concern is being considered, because its health and well-being depends on the correct administration of the drug, since the patient needs it as the disease progresses.

This study will try to show both sides under discussion in this article, analyzing both the work of physicians and also the responsibility of the state, for the benefit of society. The research methodology is theoretical bibliographic, descriptive based on bibliography found on websites of the Regional Councils of Medicine, and regional pharmacy councils, articles on the subject, Jurisprudence and books in virtual libraries.

To better understand about medical prescriptions, one should consider some factors that may impair handwriting, and the production of these prescriptions; haste, urgency, work overload, stress, double hours, few physicians and many patients, especially, are treated in public agencies, where there is a greater charge for them to meet more quickly, due to the high demand of patients[4].

It is known that it is a fact: the health professional has difficulty dealing with human error, because they are taught that they are welcoming lives and the mistakes are unacceptable. Related articles1,[5]rpotray as error identified the lack of readability in prescriptions. Several other errors occur, which are not the focus of this research, but will be described during explanations, since they usually come from the same too much haste that causes illegibility.

In this literature review, what are medical errors in a broader way were analyzed and solutions were suggested and recommended, for prevention and correction, discussing measures that can and are already being implemented in the public and private health system.

2. THE QUANTIFICATION OF THE PROBLEM

According to Zhang, Patel and Johnson[6] a medical error occurs when a health care professional chooses an inadequate method of care or improperly performs a correct method. Medical errors are often described as human errors in the area of health. However, definitions of medical error are subject to debate,[7] as there are many types of medical error, from minor to greater severity, and causality is often poorly determined.

A 2000 Institute of Medicine (IM) report written by Donaldson et al.[8] estimated that medical errors are about 40,000, and there are 98,000 preventable deaths and 1,000,000 of individuals with serious injuries and injuries resulting from the errors in hospitals in the United States of America (USA).

Some researchers, such as Hayward et al[9]. questioned the veracity of the IM study, criticizing the statistical treatment of measurement errors in the report, the significant subjectivity in determining that deaths were “preventable” or due to medical error, and an erroneous assumption that 100% of patients would have survived if better care was provided.

A 2001 study published in the Journal of the American Medical Association estimates that for every 10,000 patients admitted to hospitals, a patient dies, and this would have enjoyed up to three months or more of good cognitive health if the care provided was classified as “optimal[10].”

In 2006, another IM study found that errors in prescription reading or medication interpretation are among the most common medical errors, harming at least 1.5 million people each year. According to the study, 400,000 preventable accidents in drug administration occur each year in hospitals, 800,000 in long-term care environments (not being ICU), and about 530,000 among beneficiaries of medical plans in outpatient clinics. The report states that these are likely to be conservative estimates.

In 2000 alone, the additional medical costs incurred by preventable drug-related injuries administered, approximately $887 million – and the study looked at only injuries sustained by beneficiaries of Medicare (U.S. health plan), a subset of clinic visitors. None of these figures considers wages, lost productivity, or other costs.

According to the Health Research Agency’s quality report (2002), about 7,000 people die annually due to medication errors – about 16 percent more deaths than the number attributed to workplace-related injuries (6,000 deaths)6.

Medical errors affect one in 10 patients worldwide. An extrapolation suggests that 180,000 people die each year, partly as a result of the iatrogenic injury. One in five Americans (22%) reported that they, or a family member, have experienced a medical error of some kind6.

3. WHY DO ERRORS OCCUR?

Complicated technologies, powerful drugs, intensive care, and prolonged hospitalization can contribute to medical errors. In 2000, Donaldson et al.5 stated that the problem of medical errors are not bad people in health care, but rather that good people are working in bad systems that need to be safer.

The lines of communication and unclear and deficient between doctors, nurses and other caregivers are also contributing factors. Disconnected communication systems within a hospital can result in fragmented systems that end in numerous failures in patient outcomes[11].

Other factors include the impression that the action is being performed by other groups within the institution, the dependence on automated systems to avoid error, and inadequate systems to share information about errors, which makes it difficult to analyze contributory causes and improvement strategies. Preventive measures in hospitals in response to cost cuts can compromise patient safety. In case of emergency, prompt patient care may be provided in areas not suitable for safe monitoring[12].

The National Academy of Science has identified concerns for the design of safety and construction of health care facilities. Infrastructure failures are also a concern. According to the WHO, 50% of medical equipment in developing countries is only partially usable due to the lack of qualified operators or missing parts. As a result, diagnostic or treatment procedures cannot be performed, leading to poor quality treatment[13].

According to Hayward et al.6, The Joint Commission’s Annual Report on Quality and Safety found that inadequate communication between healthcare professionals, or between providers, and patients and family members, was the cause of more than half of serious adverse events in accredited hospitals. Other main causes included inadequate assessment of the patient’s condition, and poor leadership or training.

4. ERRORS AND JUDICIAL MEASURES

The prescription of medicines plays a crucial role in defining the characteristics of the lawsuit. Medical professionals are responsible for most of the health expenditures through their diagnostic and/or therapeutic decision. In addition, rational prescription is one of the bases of rational use and medication adhering, interfering in the outcome of treatment. The prescription is influenced by the physical conditions of care and characteristics of the health professional, such as knowledge, expertise, professional training, and its update on the efficacy and safety of old and new drugs[14].

In a study aimed at explaining the problem with medical error, referring to the illegibility of prescriptions Sant’anaet al.[15] analyzed the procedural, scientific and sanitary elements of the demands under the main variables. Among these variables were the presence of a medical prescription, adequacy of the medical prescription to good prescribing practices, among others that do not fit the main theme of this study.

The adequacy of the medical prescription to the general and legal precepts of good prescribing practices was based on 14 minimum criteria of federal standards – Federal Laws No. 5991/73b and No. 9787/99. c Ordinance No. SVS/MS 344/98d and CFF Resolution No. 357/2001. Where they were considered as “in agreement” only when the criterion was respected, for the applicable case, and for all prescribed drugs12.

In the study by Sant’Ana et al.12, no prescription was adequate to the general and legal precepts of good prescribing practices, and a median of five criteria was found in non-compliance by prescription. They also mention that there was a predominance of prescriptions originated in the SUS (Unified Health System). The most worrying is the fact that none of the prescriptions analyzed has complied with all the precepts of good prescription practices selected and that, likewise, they have been deferred and used as the content of lawsuits filed against the State by the Judiciary without requiring compliance with current health laws.

Catanheide, Lisbon and Souza[16] also refer to that errors in prescriptions can lead to a number of problems related to the use of medications, such as, for example, drug replacement and/or replacement of pharmaceutical forms in dispensing, administration of the drug in the wrong way, in the wrong dose, use beyond or below the time required or not to be treated.

And thus considering that the focus of drug lawsuits, from a legal perspective, is the health of the litigant patient, it would be important that the judicial assessment require at least compliance with the minimum requirements for a safe and adequate prescription, of which most are legal requirements12, 13.

Another fact that stands out is the low percentage of drugs prescribed by the generic name in the SUS scope, since Federal Law No. 9,787/1999 establishes the mandatory adoption of the generic name for medical and dental prescriptions of medicines. We noticed that with the illegible spelling of some medical and dental professionals, irreparable errors can be attacks on the patient. Thus, the public defender may be asking for the wrong medication due to non-readability, just as the patient can ingest a wrong medication due to the failure to communicate, which cannot occur, even by the proposal of medical professional ethics12.

Thus, because they are unable to afford consultations, medications and examinations, the hyposufficient individual has been using the Public Defender’s Office to obtain the protection of the State in medical treatment. In most cases, according to the Defenders, by proposing an action before the State in defense of the rights of the patient in court, it happens that a document is denied by the “illegible letter of doctors”, thus not being able to know what treatment and appropriate medication to be required in the action[17].

5. THE SOLUTION

There are data from hospital experience in the USA taken from spontaneous reports about errors with medications that demonstrate that 31% were related to the nursing team, 24% to the pharmacy and 13% to the medical team, and the most common incident involved the use of the wrong medication due to the confusion caused by the similarity between packaging, in addition to incomplete information, memory lapses, lack of specific knowledge and incomplete prescription[18].

Anacleto et al[19]. consider that the fundamental role lies with the hospital pharmacist in the development and execution of processes that can prevent errors in the dispensing of medications. Therefore, it represents essential importance in all stages of the process that involves the drug within the hospital institution. Its insertion in patient care, together with the multidisciplinary team, is also very important, although it is a relatively recent approach. They also report that there is a very positive impact on the reduction of errors, prevention, guidance on medications and costs of patient treatment when the clinical pharmacist is included in the health team.

As for prescription, there are several errors reported, as seen earlier. For example, the incorrect choice of medication (without checking contraindications and factors related to occurrences of allergies), inadequate doses, wrong route of administration and speed of infusion, in addition to illegible prescriptions16. Not being the purpose of this study, but among the other errors that contribute to this sad statistic, are the schedules of administration, doses, transcription of the prescription, and in the dispensing of the medication that can occur at the time of separation of the drug, in the process of preparation of the prescription by the pharmacy.

One cannot rule out the stressful factors of the medical profession, which can lead to errors. But it is also known that some strategies can reduce errors with medications[20]:

  • The standardization of processes and effective performance of the pharmacy and therapeutics committee (CFT);
  • Protocols must be in writing, and a checklist of routines and procedures should be checked;
  • Routine procedures and processes should be simplified;
  • There should be constant training, refresher classes and courses and access of all staff to this information;
  • The professional should not rely so heeds memory;
  • Changes and improvisations should be reduced in work shifts;
  • It should be encouraged the automation of all processes, with the team, (especially prescribers).

Here, the pharmacist is fundamental in the process of minimizing errors to the patient, since its functions interfere in both the administrative and clinical aspects, being a key part in guiding the structuring of all processes that can improve services. An example is the implementation of an automated information service on medicines, computerized prescription (electronic) and dispensing of medicines by sectoral characteristics (pediatrics, ICU, surgical, post-surgical, etc.)[21].

5.1 COMPUTERIZATION IN THE HOSPITAL AREA

Currently, computerization systems are used infrequently in hospital processes in Brazil. There is a great positive impact on the quality of dispensing services when they have the processes of use of computerised medicines. Therefore, computerization is a tool that should be used to reduce disorders and adverse events resulting from errors, although there are few hospitals in Brazil that already apply this technology[22].

The barcode identification system for medicines, hospital medical materials and patients, despite having a high cost, can reduce errors with medications, and can add important information, such as the entry of the drug into the hospital, the control of validities and lots, in addition to the dispensing of medications and administration, this is the whole logistical part, and also involves the nursing wing[23].

The national market has a lot of information, there are approximately one thousand five hundred drugs and more than six thousand brands, which correspond to fifteen thousand commercial presentations. Thus, it is dependent on the computerized database, so that professionals do not make errors related to medications[24].

5.2 ELECTRONIC MEDICAL PRESCRIPTION

This prescription is nothing more than a schedule, with a database that allows medical staff to prescribe all their clinical and drug decisions in computer files, replacing paper. The advantage in this system is that the prescriptions are standardized, complete and readable, thus reducing the errors arising from them. Many of these systems offer prognostic and diagnostic support in a database to assist in clinical and therapeutic decision-making[25].

Therefore, it is notorious that electronic medical prescription improves the quality of drug processes by modernizing and simplifying conventional systems, which usually involve many people, manual records and delays in many tasks and virtually nullifies the error by illegibility due to medical calligraphy.

Among the advantages of the Computerized Electronic Prescription System[26] are: better safety with data on medicines; ease to the prescribed to “cross-reference” information between the drugs to be prescribed (doses, interactions, dosages, etc.).; access to standardization of medications, diets, parenteral nutritions, chemotherapy protocols, blood products, as well as standardization of forms and routines to be followed; decreased drug incompatibilities to patients; speed and simplification of the prescription process; reduction of the costs of medications; ease of the prescriber to cross-reference information on drugs to be prescribed with radiological and laboratory tests; readability of the prescription.

Easy to store data from the medical records of each patient; reduction of related errors and medications; improving the quality of prescriptions; reduction of time spent with transcription of prescriptions, typing of requests; greater integration of the processes required by the hospital with the professionals involved; ease of follow-up and intervention in the use of antimicrobials; possibility of establishing statistics of the use of medications by therapeutic class, medical specialty, patient, consumption, among others; the possibility of establishing audits at all stages of the prescription process; greater control in the registration of drugs under special control; better integration among the professionals involved, avoiding wear and tear; better therapy to patients, reducing risks to their health; reduction of errors and consequently costs with medications and hospital processes, improving the quality of health care23.

Despite the various advantages that the implementation of a computerized electronic medical prescription system brings to the hospital institution and consequently to the health of patients, we cannot fail to consider the difficulties of this execution related to: lack of training of professionals in the area of informatics; unstable financial situation of the health sectors; lack of rigor and standardization of processes, which are often undefined in hospitals, leading to the difficulty of being computerized; rejection by the health team of process innovation and adaptation to new criteria through continuing education23.

The suggestions for the best development and implementation of the electronic medical prescription, assume that there should be a good project for execution, multidisciplinary health team involved, and a specific software for the hospital institution is always evaluated. It should be gradually implemented by ward, for better adaptation of personnel. The education and integration of personnel should be continued, with training and technical support to hospital users. Sectoral implementation should be in place, thus facilitating specific correctio[27]n.

5.3 STANDARDIZATION

A drug distribution system should be rational, efficient, economical, safe and should be in accordance with the therapeutic protocol described. The more efficient the distribution system, it maximizes the guarantee of successful treatment and prophylaxis. The aspects that must be followed as criteria are administrative and economic. As for administration, one must manage correctly to have rationalization and efficiency in distribution. It is essential that the purchasing industry is involved in such a process. As logistic control are important aspects: inventory control, standardization, involvement of trained and trained human resources for the functions and quality controls of all procedures. It is extremely important that all areas be served[28].

In the economic aspect, the pharmaceutical officer must be aware of the economic conditions in force in the country, because the institution suffers interference from both economic policy and its own economy, there should be concern about costs and revenu[29]e. There is also the culture that two employees who are not specialized and experienced (cheaper) are better than a full (more expensive) professional. Currently it has been noticed that the best option for savings is exactly the opposite, because the damage caused by incompetence causes much higher expenses, which can generate danger to the lives of patients.

There are some key and necessary requirements for the implementation of a drug dispensing system, which must be analyzed together to ensure the success of the execution of a software. The type of hospital is considered whether public or private; whether the service provided is general or specialised; and what resources are available (human material and economic).

Project scope and the project itself is better identified when written and documented, and that is discussed and improved according to the hospital’s adaptations. Remembering that each institution has its unique characteristics, and the active pharmacist should develop the project considering the political and economic reality. The higher the planning, the lower the margin of error after project execution, so it is preferable to spend more time planning and analyzing the weak and strong points of the institution[30].

5.4 STAFF TRAINING

The results of implementation and execution suggested by the hospital board, for medical, nursing and prescriber s managers, should be made. And from the moment of sensitization and mobilization should be instituted a cycle of lectures, with the intention of reaching the professionals of the other sectors of the hospital in the medication process, in a period that should be predetermined, in all three work shifts, or those that the institution present[31]s.

Later, you want them to have these lectures and courses as a permanent circle, taking place once every month. Thus, the lectures should be directed, first, to the group of prescribers, such as: heads of duty (physicians), residents of all clinics, medical students, who remain for one year in internship in the emergency sector, and then to nursing professionals26, 27.

6. FINAL CONSIDERATIONS

It is evident that errors with medicines occur due to the lack of specific knowledge, the low-skilled workforce, which can often be a strategy to reduce costs for the hospital, in addition to memory lapses, problems with the product itself, with the stability of the same, packaging, nomenclature, procedures, prescription, with the system of dispensing, distribution and administration among others.

With the review, it was seen that according to some studies it is recommended clear for prescribers the use of digitized recipes. One should also avoid the use of abbreviations, because they bring more than one interpretation, a classic example of misinterpretation is when they write ‘U’ by abbreviation of unity and who interprets confuses with a ‘zero’.

Prescribers should put data on the route of administration, pharmaceutical form and treatment time, identify with full name the patient and bed so that there is no administration of medications in another patient with similar names when not identical. As proposed, conducting educational programs focusing on understandable prescription and complete prescriptions useful to use a standard prescription model, so that there is a decrease in the occurrence of errors, because a blank prescription is much more susceptible to errors.

According to Article 35 of law 5,991 of 1973, which provides for “sanitary control of the trade in drugs, medicines, pharmaceutical and related inputs”, item “a” informs that “the prescription that is in ink will be displayed, in a vernacular in an extensive and legible manner”.

In the Code of Medical Ethics, issued by Resolution No. 1,246/88 of the Federal Council of Medicine, in Chapter III of professional responsibility, Article 39, in order to , it is “forbidden to prescribe or attest in a secret or illegible manner, as well as sign blank, prescription sheets, reports, attestates or any other documents”.

On the other hand, there is no consensus on a prescription or any other illegible writing, as there is great doubt about what a readable letter is for scholars. Determining that prescriptions are legible, without defining what this term means or which parameter defines the appropriate degree of readability does not help the doctor make his prescription more understandable.

One cannot rule out the interpretation of prescriptions, it is observed that due to the great demand, and necessary agility, often because they cannot interpret the prescription of the prescription, yet there is dispensation of a drug. Nurses, pharmacists or other health professionals, who engage in the interpretation part of recipes stop trying to “translate” illegible recipes, taking as a best way to solve this problem, the consultation with the prescriber.

From an ethical point of view, it was concluded that both areas are making mistakes, either in the prescription of prescriptions or during their interpretation, and the systems that can be adopted by the hospital to make this work less unfair, since the error can happen, but can be minimized. It is indispensable to the supervision of all medical prescriptions, and can be initiated by the patient himself when he receives it at hand, he should be instructed to question what is written to be administered safely.

It is suggested that an attitude towards the illegibility of medical prescriptions should be carried out on an emergency basis, so that deaths from drug administration errors, intoxications and health damage are reversed and that quality of life always prevails in focus. And thinking of public money, that administrations should be well controlled and fractionated to avoid wasting public funds, which weigh in the pocket of the patient himself, who is a taxpayer.

REFERENCES

ALBARRAK, Ahmed I. et al. Assessment of legibility and completeness of handwritten and electronic prescriptions. Saudi Pharmaceutical Journal, v. 22, n. 6, p. 522-527, 2014.

ANACLETO, Tânia Azevedo et al. Medication errors and drug-dispensing systems in a hospital pharmacy. Clinics, v. 60, n. 4, p. 325-332, 2005.

ARAÚJO, Patrícia Taveira de Brito; UCHÔA, Severina Alice Costa. Avaliação da qualidade da prescrição de medicamentos de um hospital de ensino. Ciência & Saúde Coletiva, v. 16, p. 1107-1114, 2011.

ASSIRI, Ghadah Asaad et al. What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature. BMJ open, v. 8, n. 5, p. e019101, 2018.

BOTELHO, Stephanie Ferreira; MARTINS, Maria Auxiliadora Parreiras; REIS, Adriano Max Moreira. Análise de medicamentos novos registrados no Brasil na perspectiva do Sistema Único de Saúde e da carga de doença. Ciência & Saúde Coletiva, v. 23, p. 215-228, 2018.

BYRNES, John. The value of physician leaders. Journal of Healthcare Management, v. 61, n. 4, p. 251-255, 2016.

CATANHEIDE, Izamara Damasceno; LISBOA, Erick Soares; SOUZA, Luis Eugenio Portela Fernandes de. Características da judicialização do acesso a medicamentos no Brasil: uma revisão sistemática. Physis: Revista de Saúde Coletiva, v. 26, p. 1335-1356, 2016.

CAVALLINI, Míriam Elias; BISSON, Marcelo Polacow. Farmácia hospitalar: um enfoque em sistemas de saúde. 2ª Ed. Manole, 2010.

CLANCY, Carolyn M. Ten years after to err is human. American Journal of Medical Quality, v. 24, n. 6, p. 525-528, 2009.

CORRIGAN, Janet M. et al. (Ed.). Priority areas for national action: transforming health care quality. National Academies Press, 2003.

DALTON, Kieran; BYRNE, Stephen. Role of the pharmacist in reducing healthcare costs: current insights. Integrated pharmacy research & practice, v. 6, p. 37, 2017.

DE MELO, Daniela Oliveira; DE CASTRO, Lia Lusitana Cardozo. Pharmacist’s contribution to the promotion of access and rational use of essential medicines in SUS. Ciencia & saude coletiva, v. 22, n. 1, p. 235-244, 2017.

DONALDSON, Molla S. et al. (Ed.). To err is human: building a safer health system. National Academies Press, 2000.

DORNAN, Tim et al. An in-depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education: EQUIP study. London: General Medical Council, p. 1-215, 2009.

HAYWARD, Rodney A. et al. Overestimating outcome rates: statistical estimation when reliability is suboptimal. Health services research, v. 42, n. 4, p. 1718-1738, 2007.

HENNEMAN, Elizabeth A. Unreported errors in the intensive care unit a case study of the way we work. Critical care nurse, v. 27, n. 5, p. 27-34, 2007.

HOFER, Timothy P.; KERR, Eve A.; HAYWARD, Rodney A. What is an error?. Effective clinical practice: ECP, v. 3, n. 6, p. 261-269, 2000.

KAUSHAL, Rainu et al. Electronic prescribing improves medication safety in community-based office practices. Journal of general internal medicine, v. 25, n. 6, p. 530-536, 2010.

LEONCINE, Maury; ABBAS, Katia; PALADINI, Edson Pacheco. Proposta de melhorias no sistema de distribuição de medicamentos para aumento da qualidade em farmácias hospitalares. In: Anais do Congresso Brasileiro de Custos-ABC. 2007.

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SHAH, Kieran et al. Bar code medication administration technology: a systematic review of impact on patient safety when used with computerized prescriber order entry and automated dispensing devices. The Canadian journal of hospital pharmacy, v. 69, n. 5, p. 394, 2016.

ULMER, Cheryl et al. System Strategies to Improve Patient Safety and Error Prevention. In: Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. National Academies Press (US), 2009.

WORLD HEALTH ORGANIZATION. Medication errors. 2016.

ZHANG, Jiajie; PATEL, Vimla L.; JOHNSON, Todd R. Medical error: Is the solution medical or cognitive?. Journal of the American Medical Informatics Association, v. 9, n. Supplement_6, p. S75-S77, 2002.

APPENDIX – FOOTNOTE REFERENCES

4. DORNAN, Tim et al. An in-depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education: EQUIP study. London: General Medical Council, p. 1-215, 2009.

5. ALBARRAK, Ahmed I. et al. Assessment of legibility and completeness of handwritten and electronic prescriptions. Saudi Pharmaceutical Journal, v. 22, n. 6, p. 522-527, 2014.

6. ZHANG, Jiajie; PATEL, Vimla L.; JOHNSON, Todd R. Medical error: Is the solution medical or cognitive?. Journal of the American Medical Informatics Association, v. 9, n. Supplement_6, p. S75-S77, 2002.

7. HOFER, Timothy P.; KERR, Eve A.; HAYWARD, Rodney A. What is an error?. Effective clinical practice: ECP, v. 3, n. 6, p. 261-269, 2000.

8. DONALDSON, Molla S. et al. (Ed.). To err is human: building a safer health system. National Academies Press, 2000

9. HAYWARD, Rodney A. et al. Overestimating outcome rates: statistical estimation when reliability is suboptimal. Health services research, v. 42, n. 4, p. 1718-1738, 2007.

10. CORRIGAN, Janet M. et al. (Ed.). Priority areas for national action: transforming health care quality. National Academies Press, 2003.

11. HENNEMAN, Elizabeth A. Unreported errors in the intensive care unit a case study of the way we work. Critical care nurse, v. 27, n. 5, p. 27-34, 2007.

12. ULMER, Cheryl et al. System Strategies to Improve Patient Safety and Error Prevention. In: Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. National Academies Press (US), 2009.

13. BYRNES, John. The value of physician leaders. Journal of Healthcare Management, v. 61, n. 4, p. 251-255, 2016.

14. MAXWELL, Simon RJ. Rational prescribing: the principles of drug selection. Clinical Medicine, v. 16, n. 5, p. 459-464, 2016.

15. SANT’ANA, João Mauricio Brambati et al. Racionalidade terapêutica: elementos médico-sanitários nas demandas judiciais de medicamentos. Revista de Saúde Pública, v. 45, p. 714-721, 2011.

16. CATANHEIDE, Izamara Damasceno; LISBOA, Erick Soares; SOUZA, Luis Eugenio Portela Fernandes de. Características da judicialização do acesso a medicamentos no Brasil: uma revisão sistemática. Physis: Revista de Saúde Coletiva, v. 26, p. 1335-1356, 2016.

17. ARAÚJO, Patrícia Taveira de Brito; UCHÔA, Severina Alice Costa. Avaliação da qualidade da prescrição de medicamentos de um hospital de ensino. Ciência & Saúde Coletiva, v. 16, p. 1107-1114, 2011.

18. ASSIRI, Ghadah Asaad et al. What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature. BMJ open, v. 8, n. 5, p. e019101, 2018.

19. ANACLETO, Tânia Azevedo et al. Medication errors and drug-dispensing systems in a hospital pharmacy. Clinics, v. 60, n. 4, p. 325-332, 2005.

20. WORLD HEALTH ORGANIZATION. Medication Errors: Technical Series on Safer Primary Care, 2016.

21. DE MELO, Daniela Oliveira; DE CASTRO, Lia Lusitana Cardozo. Pharmacist’s contribution to the promotion of access and rational use of essential medicines in SUS. Ciencia & saude coletiva, v. 22, n. 1, p. 235-244, 2017.

22. LEONCINE, Maury; ABBAS, Katia; PALADINI, Edson Pacheco. Proposta de melhorias no sistema de distribuição de medicamentos para aumento da qualidade em farmácias hospitalares. In: Anais do Congresso Brasileiro de Custos-ABC. 2007.

23. SHAH, Kieran et al. Bar code medication administration technology: a systematic review of impact on patient safety when used with computerized prescriber order entry and automated dispensing devices. The Canadian journal of hospital pharmacy, v. 69, n. 5, p. 394, 2016.

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[1] General Practitioner graduated from UNIMES – Metropolitan University of Santos, city of Santos/ SP. Lawyer and bachelor’s degree in law from CESUR – Center for Higher Education of Rondonópolis, city of Rondonópolis/ MT. Postgraduate in Labor Procedural Law from UGF – Gama Filho University.

[2] Physiotherapist graduated from PUC-GO – Pontifical Catholic University of Goiás, city of Goiânia/GO. Academic of the 6th year of the medical course at UNIMES – Metropolitan University of Santos.

[3] Veterinary Physician graduated and Master’s degree from UFMT – Federal University of Mato Grosso, city of Cuiabá/ MT. Academic of the 3rd year of the medical course of FAMP – Morgana Potrich College, city of Mineiros / GO.

Sent: January, 2020.

Approved: January, 2020.

Generalist Doctor graduated from UNIMES - Metropolitan University of Santos, city of Santos / SP. Lawyer and bachelor of law degree from CESUR - Center of Higher Education of Rondonópolis, city of Rondonópolis / MT. Postgraduate in Procedural Labor Law at UGF - Gama Filho University.

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