Prescripción médica y su aplicación posterior a un sistema de vigilancia farmacológica en Medicina Interna. Hospital General Dr. Miguel Silva
RESUMEN
Antecedentes: los registros médicos correctos evitan omisiones, errores de medicación, reacciones adversas a medicamentos, muertes acompañadas de demandas al personal de salud y baja calidad en la atención al paciente (NOM-168-SSA-1998). Objetivo: identificar la diferencia entre el registro de la prescripción y la aplicación de los medicamentos antes y después de la implantación de un sistema de vigilancia farmacológica en el servicio de Medicina Interna. Material y método: estudio retrospectivo, descriptivo y transversal realizado en dos periodos entre octubre de 2006 y enero de 2009 en el Hospital General Dr. Miguel Silva de la ciudad de Morelia, Michoacán, con 107 prescripciones asentadas en expedientes clínicos completos. Se señalaron los medicamentos registrados como prescritos no aplicados y los registrados como aplicados no prescritos. Resultados: se encontró incompatibilidad entre los registros de prescripción médica y la aplicación por parte de las enfermeras en ambos periodos estudiados; sin embargo, entre el primero y último estudio hubo una diferencia significativa con χ2 (P =
Palabras clave: vigilancia farmacológica, prescripción, aplicación, expediente clínico
ABSTRACT
The accurate medical records avoid omissions and incomplete notes and / or mistaken notes, which contributes also to avoid a current problem within the hospitals called Medication Errors (ME), often caused because the low quality of the clinical files according to the NOM- 168-SSA-1998 and therefore a poor medical attention to the patient, causing adverse drug reactions or even death and the possibility of lawsuits against people related to the health care. The aim of this study was to identify if there is a difference between registration and implementation of prescription drugs before and after the implementation of a drug monitoring system in the internal medicine specialty, it was developed in two periods with three years of difference between each one; the study was retrospective, descriptive and transversal and was realized in General Hospital «Dr. Miguel Silva «in the city of Morelia Michoacán. It included 107 medical indications from complete clinical records of October 2006 and 99 from January 2009; bearing in mind medicines prescribed but not applied, and applied medicines that were not prescribed as well. Incompatibility was found among the records of clinical prescription and implementation by nursing staff in both studied periods. However, the comparison between the first and the last period shows a significant difference of χ2 (P =
Keywords: implementation, clinic file, prescription, drug monitoring system
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