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To analyze the results of sentinel patient program to monitoring the quality pharmacoterapeutic process in the hospitalized patient through medication errors.
Design: Observational, prospective and transversal study. Ambit: General hospital of 1,000 beds.
From May 2011 to June 2016. Sample: Patients with treatment prescribe within 24 hours of being admitted with 4 or more medications.
Medication error, drugs prescribed, medications and doses dispensing, drugs administered. Safety indicators were defined based on medication errors at each stage of the pharmacotherapeutic process.
Of the 746 patients studied, 334 had at least 1 medication error (44.8%; IC95%: 41.7-47.8). In the 746 treatments, 564 medication errors were detected (0.75 errors by patient; IC95%: 0.7-0.8). The safety indicators (medication error by stage) were: 5.1% (38/746 patients) for omission of allergy record; 2.3% (156/6 724 drugs) for prescription; 0.6% (38/6 724 drugs) for validation, 2.6% for dispensing (142/5 465 drugs) y 3.7% (190/5 111 administered drugs observed) for administration. The temporal evolution of the indicators, with graphs of statistical control showed stable processes, except for the administration. The proposed improvement actions were of a training, standardization and organizational type.
The sentinel patient program provides an overview of the quality of the pharmacotherapeutic process and promotes the safety culture at the center. Statistical control charts have been a useful tool for monitoring medication errors. The analysis of medication errors has served to propose improvement actions in each stage of the pharmacotherapeutic process.