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- Title
ACTIONS IMPLEMENTED IN THE PREPARATION AND ENDOVENOUS ADMINISTRATION OF HEPARIN: ADVERSE EVENT REPORT.
- Authors
Echer, Isabel Cristina; Boni, Fernanda Guarilha; de Quadros, Deise Vacario; Osmarin, Viviane Maria; Rotta, Eloni Terezinha; Wegner, Wiliam
- Abstract
Objective: to report an adverse event in the preparation and endovenous administration of heparin and actions implemented by the health team. Methods: this is an experience report on the actions implemented after analyzing an adverse event in the preparation and administration of heparin in a patient admitted to a University Hospital in southern Brazil. Data were collected from the patient's medical records, minutes of meetings of the teams involved, and the action plan of the measures instituted after an event that occurred in November 2017. Results were analyzed in a descriptive manner and the project was approved by the Research Ethics Committee. Results: the actions carried out included the review of routines and protocols related to the calculation of dose, preparation, and endovenous administration of heparin. There was inclusion as a high-alert medication and double checking. Institutional-level guidelines and alerts were also released to all members of the nursing team. Conclusion: the experience contributed to highlight the need to monitor incidents and their impacts, find strategies to reduce them through process reviews and implementation of actions in care practice aiming at greater safety in the preparation and endovenous administration of heparin.
- Subjects
BRAZIL; PREVENTION of drug side effects; NURSING; ACADEMIC medical centers; ACQUISITION of data methodology; RESEARCH methodology; MEDICATION errors; MEDICAL records; HEPARIN; RISK management in business; PATIENT safety
- Publication
Ciencia, Cuidado e Saude, 2021, Vol 20, p1
- ISSN
1677-3861
- Publication type
Article
- DOI
10.4025/cienccuidsaude.v20i0.52102