Erros de medicação podem custar 42 bilhões de dólares – 136 bilhões de reais – e matar ao menos uma pessoa por dia no mundo, todos os anos

(Divulgação) Kit Psicobox

Cirurgia colorida e mais segura: Workshop de Inovação e Gestão em Anestesiologia para Centro Cirúrgico, que entre outros temas apresentará “Condutas e Tecnologias para Controle de Erros de Administração de Medicação”, terá apoio dos kits e do carro auxiliar para cirurgia da Psicobox, que separam e identificam medicamentos e equipamentos por módulos, cores e etiquetas

Inscreva-se!

Custos relacionados a erros no uso de medicações chegam 42 bilhões de dólares – cerca de 136 bilhões de reais ou quase 1% do total das despesas de saúde – por ano no mundo, segundo estimativa da Organização Pan-Americana da Saúde da Organização Mundial da Saúde (OPAS/OMS). Ao menos uma pessoa morre, por dia, apenas devido a erros no uso de medicamentos. Somente nos Estados Unidos, aproximadamente 1,3 milhão de pessoas são prejudicadas, todos os anos, por esses enganos.

Erros de medicação são as causas mais comuns de morbidade e mortalidade de pacientes, segundo o artigo “Erros de Medicação em Anestesia: Inaceitável ou Inevitável?”, publicado na Revista Brasileira de Anestesiologia: “Mais pessoas morrem devido a erros médicos do que de acidentes automobilísticos, câncer de mama ou HIV”.

Não é de admirar que a implementação de práticas para evitar a ocorrência de eventos adversos envolvendo medicamentos seja a terceira das seis Metas Internacionais de Segurança do Paciente da Organização Mundial da Saúde. Entre as práticas recomendadas estão o uso de rótulos auxiliares e alertas automáticos.

Em tempos de “errar é humano”, podemos lembrar ainda o que diz o livro Patient Safety and Quality – An Evidence-Based Handbook for Nurses sobre o impacto do ambiente na segurança e no desempenho humano: “É básico compreender ‘as interrelações entre os seres humanos, as ferramentas que usam e o ambiente em que vivem e trabalham’ para qualquer estudo de design de um serviço de saúde e seu efeito no desempenho de enfermeiros e outros profissionais que fazem interface entre as instalações e seus equipamentos e tecnologias fixos (como posto de rede de gases na parede de um quarto de hospital) e móveis (como leitos). Os seres humanos não se comportam sempre de modo desajeitado e nem sempre erram, mas são mais propensos a fazê-lo quando trabalham em um cenário mal concebido e mal projetado”.

Medicamentos e materiais com nome e aparência semelhante

Ao longo de sua vida profissional, um médico anestesiologista pode injetar até meio milhão de drogas diferentes. Assim, um dos temas do Workshop de Inovação e Gestão em Anestesiologia para Centro Cirúrgico do 8º AnestEdu, que ocorre no Hospital Novaclínica, é “Condutas e Tecnologias para Controle de Erros de Administração de Medicação”. Nele, a WMC Anestesia contará com o apoio da Psicobox, fabricante de carros e kits hospitalares personalizados, que separam e identificam medicamentos e materiais, como seringas e ampolas, em módulos, cores e etiquetas.

Confusões com nomes de medicamentos LASA (Look-Alike/Sound-Alike), ou seja, medicamentos de nome e aparência semelhante, geram até 25% de todos os erros de medicação. Trinta e três por cento de todos os erros de medicação são atribuídos a trocas de embalagem e rotulagem (informações dos livros Reducing Medication Errors Through Naming, Labeling and Packaging, de Adrienne Berman, e A Tall Man Lettering Project to Enhance Medication Safety, de Cohen e David.

Um dos motivos de causa de erro em administração de medicamentos em centro cirúrgico é rotulagem/identificação/seleção imprópria. “As embalagens das ampolas, bem como os nomes dos medicamentos, em alguns casos, são muito parecidas. Os produtos Psicobox ajudam na implementação de procedimentos e rotinas que possibilitem ‘barreiras’ de segurança, para que não aconteçam erros”, afirma Denis Massagli, proprietário e fundador da empresa e idealizador do conceito da Psicobox, que, em apoio ao workshop do 8º AnestEdu, irá fornecer, para as quatro salas de cirurgia no Hospital Novaclínica, kits e carros auxiliares personalizados. Ele explica que os produtos acondicionam de forma individualizada cada tipo de ampola, identificam o princípio ativo e o nome comercial do medicamento desde o armazenamento até a seringa aspirada, além de separar, no arranjo do projeto, ampolas que são parecidas (gerenciamento de risco por posicionamento) e utilizar cores normatizadas para melhor gestão visual (ISO 26825 / 2008 – ISO 14490 / 2000): “Para ampolas e medicamentos, é confeccionado um suporte com furos e identificações. O acondicionamento é na vertical para melhor visualização. O furo faltante indica o medicamento que já foi utilizado, o que facilita a reposição. Para materiais, são confeccionadas divisórias modulares, com as identificações do nome e da quantidade de cada item”.

Segundo Massagli, o sistema, que foi desenvolvido pela empresa por um projetista e um médico anestesiologista, tem um custo que se paga com folga por evitar os eventos adversos, que custam muito mais caro. Além disso, acreditações, certificações, programas de compliance e governança clínica e corporativa estão, cada vez mais, exigindo que hospitais e instituições prestadoras de serviços de saúde implementem práticas que combatam eventos adversos e erros desde a prevenção.

Veja também: Você já se comprometeu com o compliance hoje? Comprometimento é o desafio para o compliance na saúde

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