miolo sho2009_indices v8 - Departamento de Produção e Sistemas ...

safe for use. The introduction of collaborative cross-checks should also increase theidentification of errors associated with errors related to the use of new drugs.CONCLUSIONAll staff groups have the potential to cause an error and all have the opportunity to identify andrecover errors. The consequences of medication administration errors can be extreme, e.g.patient fatality, but most present several opportunities for error recovery. The provision ofeducation for healthcare professionals relating to human performance limitations wouldempower healthcare staff to recognize operating conditions which are likely to increase thepotential for error occurrence and error detection. The identification of work periods thatincrease the likelihood of error occurrence could heighten staff vigilance for the potential of erroroccurrence and propagation, and increase the potential awareness for error recovery.Medication administration errors have the potential to be recovered at several stages within theadministration process. Educating healthcare staff in human error and human performancelimitations, along with the additional collaborative cross-checks in the administration processand clearly defining staff roles and functions should reduce the potential for error in critical carework environment.Sho2009REFERENCES[1] COLPAERT, K., CLAUS, B., SOMERS, A., VANDEWOUDE, K., ROBAYS, H. & DECRUYENAERE,J. (2006) Impact of computerized physician order entry on medication prescription errors in theintensive care unit: a controlled cross-sectional trial. Critical Care, 10, R21.[2] MEKHJIAN, H. S., KUMAR, R. R., KUEHN, L., BENTLEY, T. D., TEATER, P., THOMAS, A., PAYNE,B. & AHMAD, A. (2002) Immediate Benefits Realized Following Implementation of Physician OrderEntry at an Academic Medical Center. J Am Med Inform Assoc, 9, 529-539.[3] ASH, J. S., GORMAN, P. N., SESHADRI, V. & HERSH, W. R. (2004) Computerized Physician OrderEntry in U.S. Hospitals: Results of a 2002 Survey. J Am Med Inform Assoc., 11, 95–99.[4] SENDERS, J. W. (1994) Medical Devices, Medical Errors, and Medical Accidents. IN BOGNER, M.S. (Ed.) Human Error in Medicine. Hove, UK, Lawerence Erlbaum Associates.[5] SCHNEIDER, P.J., 2002. Applying human factors in improving medication-use safety. Am. J. HealthSyst. Pharm. 59 (12), 1155–1159.[6] PATTERSON, E., WOODS, D., COOK, R. & RENDER, M. (2007) Collaborative cross-checking toenhance resilience. Cognition, Technology & Work, 9, 155-162.[7] KIRWAN, B. (1994) A Guide to Practical Human Reliability Assessment, London, Taylor and Francis.[8] KIRWAN, B. (1998) Human error identification techniques for risk assessment of high risk systems--Part 1: review and evaluation of techniques. Applied Ergonomics, 29, 157-177.[9] TANG, B., HANNA, G. B. & CUSCHIERI, A. (2005) Analysis of errors enacted by surgical traineesduring skills training courses. Surgery, 138, 14-20.[10] TANG, B., HANNA, G. B., JOICE, P. & CUSCHIERI, A. (2004) Identification and categorization oftechnical errors by observational clinical human reliability assessment (OCHRA) during laparoscopiccholecystectomy. Arch Surgery, 139, 1215-1220[11] WHITTINGHAM, R. B. (2004) The Blame Machine: Why Human Error Causes Accidents, Oxford,Elsevier Butterworth-Heinemann.Colóquio internacional sobre segurança e higiene ocupacionais147