Implemented Improvement: Medication Error Prevention

Abstract

Medication errors are, above all, preventable events. The vast supply of antiretrovirals3 with complex names and similar vials is a concern regarding the accuracy of dispensing and using the cocktail. Objective: to describe the contributions of the strategy to prevent errors in dispensing antiretroviral drugs for HIV-positive individuals in nursing work. Method: this is an experience report on the organization and dispensing of antiretrovirals for 47 HIV-positive patients in the STI/HIV/AIDS sector of Prudentópolis/PR. Results and Discussion: In order to minimize the risk of errors and streamline the service, a color and letter system was organized to correlate the cocktails and patients, and patient listening was intensified. The medications are delivered monthly/bimonthly from the SAE of Guarapuava/PR. After checking, they are separated into opaque packages and labeled with the patient's first name in the same standardized color as the cocktail used. Ex: (3 in 1 = A – red); (Tenoforir/Lamivudine + Dolutegravir = B – green), etc. Conclusion/Final Considerations: After identifying the risk of errors, color and letter identification systems were applied, making organization faster and dispensing safer, and also making it easier for patients to recognize. Listening to patients was also intensified. Proving that the nursing profession can make a difference in the effectiveness of antiretroviral treatment results.