Medication error notifications in Primary Health Care of a Brazilian capital: an analysis from the perspective of patient safety

Vigil Sanit Debate, Rio de Janeiro, 2025, v.13: e02383 | Published on: 01/12/2025

Abstract

Introduction: Medication errors are preventable events that may lead to inappropriate medication use and are associated with various stages of the medication process, including prescribing, dispensing, and administration. Such errors can result in severe clinical consequences for patients and impose significant financial burdens on healthcare systems. While most data on the frequency and impact of medication errors come from hospital-based studies, research on these errors in Primary Health Care (PHC) remains scarce. Objective: This study aimed to analyze medication error reports originating from PHC in the Unified Health System (SUS) in Belo Horizonte, Minas Gerais, Brazil. Methods: An exploratory and descriptive study was conducted using a quantitative approach. A total of 1,174 reports filed in the Municipal Notification System between February 2020 and February 2023 were analyzed. Results: The most frequent errors were dispensing errors (73.0%), followed by prescribing errors (23.0%) and medication administration errors (4.0%), primarily involving antihypertensives, antidiabetics, and anticonvulsants. The most common error was dispensing the wrong medication to the patient. Most cases occurred in women (60.0%), with a predominance in the age group of > 60 years (37.4%). Although most errors did not harm patients (96.3%), mild (2.6%) and severe (1.1%) adverse events, including one fatal case, were reported. Among the errors with mild consequences, 25.0% involved potentially dangerous medications. In severe cases, this proportion reached 38.0%. Conclusions: This study showed that the most frequently reported medication errors in PHC in Belo Horizonte were related to the dispensing stage, with a greater impact on women and the elderly. Although most errors did not result in harm, the occurrence of adverse events—including one death—and the high association with hazardous medications highlight the need for improvements in dispensing processes, high-risk medication protocols, and targeted strategies for vulnerable groups to enhance patient safety in PHC units. In this context, the implementation of Patient Safety Centers stands out as an essential strategy to organize care and promote necessary changes.