Fatores relacionados aos erros de medicação no cuidado em neonatologia e estratégias de prevenção em hospitais brasileiros: uma revisão integrativa

Abstract

Objective: To identify factors related to the occurrence of medication errors in neonatal care in Brazilian hospitals and to describe the strategies proposed or used for their prevention. Method: This is an integrative literature review, conducted according to the methodological steps described by Dantas et al., including the definition of the research question, eligibility criteria, literature search and selection, data extraction, and analysis. The documentary research protocol detailed all procedures adopted. The literature search was carried out in the following databases: Latin American and Caribbean Health Sciences Literature (via Virtual Health Library), Scientific Electronic Library Online (SciELO), Scopus, Web of Science, and Medline (via PubMed). Results: Eleven studies were included in the final sample. The most frequently addressed types of medication errors involved: dosage errors (underdose/overdose), dilution and preparation of intravenous medications, administration frequency, dose omission, and failures in aseptic technique. The identified risk factors were grouped into three dimensions: (1) related to the professional, such as inexperience, lack of specific training, work overload, and failures in multiprofessional communication; (2) organizational, such as absence or weakness of standardized protocols, unavailability or inadequate use of computerized systems, and inadequacies in the physical environment for medication preparation; and (3) related to the patient and therapy, such as extreme prematurity, polypharmacy, clinical complexity of newborns, and use of high-risk medications. Conclusion: Medication errors in hospital neonatal care constitute a multifactorial phenomenon, resulting from the interaction of human, organizational, and clinical factors. The strategic role of hospital management is evident in promoting safer care environments through resource allocation, strengthening the institutional safety culture, and systematically implementing safe practices in the neonatal care routine.