PERFIL Y ANÁLISIS DE PARETO DE LOS ERRORES DE DISPENSACIÓN DE UN HOSPITAL PUBLICO
Rafaela Sirtoli, Eliz Cassieli Pereira Pinto, Carine Fieira, Jeferson Giovan Volkweis, Suelem Tavares da Silva Penteado, Luciane de Fátima Caldeira

Objective: To describe the profile of the dispensing errors identified through the drug strip conference by the hospital pharmacist and to quantify the discrepancies generated by the indicator in a high complexity hospital in the State of Paraná, in 2015. Method: Cross-sectional and retrospective study of dispensing errors that were avoided by the pharmacist. Once identified, the discrepancies were classified and counted, generating an indicator of the work process (number of avoided errors/number of dispensed strips x 100). Subsequently, a Pareto Analysis was performed in order to prioritize problem solving actions. Results: A total of 27,980 prescriptions were obtained, which originated 48,451 drug strips in the study period. The dispensing errors encountered during the conference of the strips by the pharmacist amounted to 1,453. The dispensing error rate was 3 errors per 100 strips. The most frequently occurring errors were lack of medication and change of medication schedule, representing 61% of all errors together. The same errors were identified in the analysis in the Pareto Diagram as the main intervention targets in the improvement of the processes. Conclusion: The occurrence of errors found through the indicator "Index of Dispensation Errors" was considered low, compared to what was read in the available literature. Through Pareto Analysis, it was possible to identify the most frequent errors, the ones that should be considered in the planning of improvement measures, aiming for the increase of patient safety.

Descriptores: Errores de medicación; seguridad del paciente; indicadores de calidad en salud.