CHARACTERI ZATI ON OF THE STRUCTURE FOR MEDI CATI ON PREPARATI ON I N
TEACHI NG-HOSPI TALS: FACTORS THAT I NTERFERE W I TH THE QUALI TY OF CARE
Regina Célia de Oliv eir a1 Sílv ia Helena De Bor t oli Cassiani2
Oliveira RC, Cassiani SHB. Charact erizat ion of t he st ruct ure for m edicat ion preparat ion in t eaching- hospit als: fact ors t hat int erfere wit h t he qualit y of care. Rev Lat ino- am Enferm agem 2007 m arço- abril; 15( 2) : 224- 9.
This art icle describes t he physical environm ent , m at erial and hum an resources of t he st ruct ure for t he preparat ion of m edicam ent s. I t is an explorat ory descript ive st udy. Dat a were collect ed t hrough script s st ruct ured for obser v at ion and int er v iew car r ied out w it h a sam ple of 92 ( 76% ) nur se aux iliar ies and all nur ses of, t w o h ospit als in Recif e, PE, Br azil. Resu lt s sh ow ed t h at t h e en v ir on m en t in w h ich m edicat ion is pr epar ed is in disagr eem ent w it h cur r ent legislat ion, t he av ailable m at er ials need t o be r ev iew ed and pr ofessionals need t o get t heir knowledge updat ed. I t is concluded t hat t he st ruct ure in t he syst em of m edicat ion is essent ial and t he fact ors point ed out in t he st udy int erfere w it h t he qualit y of t he process of m edicat ion.
DESCRI PTORS: healt h facilit ies, hum an r esour ces, m anpow er ; or ganizat ion and adm inist r at ion; t her apeut ics; n u r sin g
CARACTERÍ STI CAS EN LA ESTRUCTURA PARA LA PREPARACI ÓN DE MEDI CAMENTOS EN
HOSPI TALES DE ENSEÑANZA : FACTORES QUE I NFLUYEN EN LA
CALI DAD DE LA ASI STENCI A
Est e ar t ículo descr ibe la est r uct ur a de pr epar ación de m edicam ent os en su am bient e físico, r ecur sos m at er iales y h u m an os. Se t r at a d e u n est u d io ex p lor at or io d escr ip t iv o. Los d at os f u er on r ecolect ad os p or m edio de guías est r uct ur adas t ant o par a la obser v ación y ent r ev ist a, las cuales fuer on aplicadas en 9 2 % y 7 6 % de los au x iliar es de en fer m er ía y en el 1 0 0 % de los en fer m er os de dos h ospit ales de Recife, PE. Los r esult ados m uest r an que el am bient e de pr epar ación de m edicam ent os no est a de acuer do con la legislación v igent e, consider ando que los m at er iales r equier en ser r ev isados y los pr ofesionales capacit ados. Se concluy e qu e la est r u ct u r a den t r o del sist em a de m edicación es esen cial y qu e los fact or es señ alados in flu y en en la calidad de t al pr oceso.
DESCRI PTORES: i n st i t u ci o n es d e sal u d ; r ecu r so s h u m an o s; o r g an i zaci ó n y ad m i n i st r aci ó n ; t er ap éu t i ca; en f er m er ía
CARACTERI ZAÇÃO DA ESTRUTURA PARA O PREPARO DE MEDI CAMENTOS EM HOSPI TAI S
DE ENSI NO: FATORES QUE I NTERFEREM NA QUALI DADE DA ASSI STÊNCI A
Est e art igo descreve a est rut ura do preparo de m edicam ent os em seu am bient e físico, recursos m at eriais e h u m an os. Tr at a- se d e est u d o ex p lor at ór io e d escr it iv o. Os d ad os f or am colet ad os p or m eio d e r ot eir os est rut urados para observação e ent revist a, aplicados em am ost ras de 92 e 76% dos auxiliares de enferm agem e 100% dos enferm eiros, em dois hospit ais na cidade de Recife, PE. Os result ados m ost raram que o am bient e do pr epar o de m edicam ent os se encont r a em discor dância com a legislação v igent e, os m at er iais disponív eis p r ecisam ser r ev isad os e os p r of ission ais n ecessit am d e cap acit ação. Con clu iu - se q u e a est r u t u r a em u m sist em a de m edicação é essencial e que os fat ores apont ados int erferem na qualidade do processo de m edicação.
DESCRI TORES: inst it uições de saúde, recursos hum anos; organização e adm inist ração; t erapêut ica; enferm agem
1 RN, Adj u n ct Pr of essor at College of Nu r sin g Nossa Sen h ora das Gr aças, Un iv er sit y of Per n am bu co, e- m ail: r egin aoliveir a@f en sg. upe. br, reginac_oliveira@terra.com .br; 2 RN, Full Professor at University of São Paulo at Ribeirão Preto College of Nursing WHO Collaborating Centre for Nursing Research Developm ent , e- m ail: shbcassi@eerp.usp.br
I NTRODUCTI ON
T
ech n o l o g i cal ch an g es ex er t ed a st r o n g influence on health care. These changes are reflected in the constant search for quality, a tendency im ported fr om lar ge indust r ies w hich st ar t s t o t ak e ov er t he health industry as well. The need to change the health scenario is prom pt by the expectations of professionals, client s and societ y in gener al. The par adigm s t hat guided the adm inistration of health institutions no longer fit in the advancem ents achieved in this new m illennium , and qualit y has becom e im perat ive( 1).I t is understood that the im provem ent of care occurs through the evaluation of health services, which t herefore need crit eria and est ablished pat t erns. The cr i t e r i a a n d p a t t e r n s cu r r e n t l y u se d i n h e a l t h in st it u t ion s goin g t h r ou gh accr edit at ion pr ocesses follow an evaluation m odel that is based on the quality aspect s: st r uct ur e, pr ocess and r esult s, defined by Av edis Donabedian( 2).
This ev aluat ion m odel is based on gener al sy st em s t heor y and on t he w or k of Mindel Sheps. Th u s, st r u ct u r e, p r o cess an d r esu l t s co m p o se a sy st em ic m odel and for m an int er dependent chain w it h a nar r ow m ut ual cause- and- effect r elat ion. I n this context, the structure is com posed of a building, hum an resources ( quantity, category and professional q u al i f i cat i o n ) , o r g an i zat i o n al st r u ct u r e, m at er i al resources and norm at ive inst rum ent s( 2).
The structure is, therefore, one of the essential aspect s when at t em pt ing t o know t he funct ioning of the hospital system or subsystem of a health service. Even if the com bination of structure, process and result dat a is required t o obt ain t he best qualit y assessm ent strategies, it is understood that the relation b e t w e e n st r u ct u r e a n d ca r e q u a l i t y r e v e a l s i t s im port ance, considering t hat a good st ruct ure m eans sufficient resources and adequat e syst em design( 3).
Ba se d o n t h e a b o v e a n d k n o w i n g t h a t m ed icat ion u sag e con st it u t es a su b sy st em in t h e hospit al cont ext , t his st udy aim s t o: charact erize t he m edication preparation structure in teaching hospitals r eg ar d in g it s p h y sical en v ir on m en t , m at er ial an d h u m a n r eso u r ces; a n d i d en t i f y t h e f a ct o r s t h a t int erfere in care qualit y.
METHODOLOGY
This is an explorat ory and descript ive st udy, designed t o at t end t he peculiarit ies of t his research.
The investigation was carried out in the m edical clinic ar ea of t w o public hospit als in Recife, Br azil, between October and Decem ber 2004. Both institutions ar e r elat ed w it h t each in g an d r esear ch act iv it ies, because they develop m edical, nursing and pharm acy residence program s. The sam ple consisted of 14 nurses (100% ) in both hospitals. Secondary-level professionals represented 92% ( 34) and 76% ( 15) in the first and second inst it ut ion, respect ively. I n t he t ext , t hey are referred to as Hospital 1 and Hospital 2.
Data were collected after the approval of the Et hics Com m it t ee, using non- part icipant observat ion and int erviews t hrough st ruct ured script s. Two kinds of st r uct ur ed inst r um ent s w er e elabor at ed for dat a collect ion: one observat ion script and one int erview script. Results were organized and described ac follows.
RESULTS
I n t his st udy, m edicat ion is prepared in t he n u r sin g ser v ice r oom . Th is en v ir on m en t m easu r es 14.8 m2 in Hospital 1 and 12.3 m2 in Hospital 2, and is
located in a central position towards the nursing ward. These rooms are artificially illuminated, protecting t he env ir onm ent against sunlight . I llum inat ion w as considered sufficient at Hospital 1 but insufficient at 2, taking into account that the ceiling was more than three m eters high, with only two fluorescent lam ps available. Ventilation is natural and occurs indirectly, since there are no windows in the room s. However, in addition to natural ventilation, a fan on the ceiling offers artificial ventilation at Hospital 2.
Furniture found in the nursing services room is dest ined t o st ore t he hospit al- m edical m at erials and in d iv id u al d oses f or m ed icat ion p r ep ar at ion an d adm inistration. The study identified, at the institutions, cabinets with drawers, wall cabinets and balcony cabinets. There are exclusive refrigerat ors t o preserve m edication. There are no norm s available at the sector a b o u t t h e p r e se r v a t i o n o f m e d i ca t i o n u n d e r refrigeration, such as those related to the conservation of parenteral solutions of large volum e. Manuals with n o r m s, r o u t i n e s a n d p r o ce d u r e s r e l a t e d t o t h e co n se r v a t i o n a n d st o r a g e o f p sy ch o t r o p i cs a n d narcotics were not available either, not even regarding m edicat ion preparat ion and adm inist rat ion.
preparation, there are sinks for hand washing with manual taps. These sinks are supplied with liquid soap and paper towels; 70% alcohol to disinfect m edication bottles and am poules of m edicat ion, t rays and basins. To discard p ier cin g - cu t t in g m at er ial, t h er e ar e ap p r op r iat e descartexÒ containers.
The devices ident ified t o support m edicat ion adm inist r at ion w er e infusion pum ps. These hav e a st andard m odel, regist ered at t he Healt h Minist ry, at both institutions. At Hospital 1, these pum ps are stored by an equipm ent cent r al, r esponsible for cleaning, periodical m aint enance and disinfect ion, according t o guidelines by the Hospital I nfection Control Com m ittee ( HI CC) . This central has 271 infusion pum ps available for t he hospit alizat ion unit s. At Hospit al 2, four unit s of t his dev ice w er e found, w it h a st andar d m odel, w h i ch a r e a v a i l a b l e a t t h e se ct o r. Th e n u r si n g p r o f e ssi o n a l i s r e sp o n si b l e f o r cl e a n i n g a n d disinfection. Maintenance is not perform ed periodically. For or al m edicat ion pr epar at ion, Hospit al 1 does not have a specific cont ainer available. Hospit al 2, on t he ot her hand, every day request s fift y sm all disposable cups, and also has a m ort ar t o t rit urat e m edicat ion for adm inist rat ion by nasoent eral probe. Regarding parent eral m edicat ion preparat ion, it was observed t hat different opt ions of m at erial t o p r e p a r e sm a l l a n d l a r g e v o l u m e s o f p a r e n t e r a l so l u t i o n s w e r e o n l y a v a i l a b l e f o r sy r i n g e s, v en ipu n ct u r e cat h et er s an d ser u m dev ices. Th er e were only t hree opt ions of hypoderm ic needle sizes and calibers ( 40x12; 25x7; 13x0, 45) .
At Hospit al 1, an adhesive label is required, to be filled out by the nurse to identify the m edication. At Ho sp i t al 2 , m ed i cat i o n t o b e ad m i n i st er ed i n syringes is identified with gum m ed tape, while m arker pens are used to identify intravenous solutions of large volum e and m edicat ion in disposable cups.
Me d i ca t i o n f o r a d m i n i st r a t i o n ca n b e t r an sp or t ed on t r ay s or k id n ey b asin s esp ecially dest ined for t his purpose.
Professionals wit h higher educat ion degrees are available t o prepare t he prescribed drugs. These ar e nur ses w ho, am ong t heir at t r ibut ions, m ust be qualified t o execut e t his act ivit y as well as t o guide, train and supervise nursing technicians and auxiliaries to perform this task. We identified ten nurses ( 100% ) at Hospital 1 and four ( 100% ) at Hospital 2, who work 30 hours per week.
I n t h e r e a l i t y o f Br a zi l i a n i n st i t u t i o n s, m edicat ion preparat ion and adm inist rat ion has been the responsibility of nursing technicians and auxiliaries.
The nursing professionals are dist ribut ed in shifts of 12 X 60 hours for the day and night period. At Ho sp i t a l 1 , i n t o t a l , t h e r e a r e 3 4 n u r si n g professionals, dist ribut ed as follows: 53% in t he day shift and 47% in t he night shift . Hospit al 2 has 16 professionals, 50% in each shift. At these institutions, a m aj orit y of professionals are nursing auxiliaries.
Th ese p r of ession als h av e p er f or m ed t h eir functions at the m edical clinics of both hospitals, which include m edication preparation and adm inistration, for m or e t h an f iv e y ear s. Reg ar d in g t h e h an d lin g of infusion pum ps, used to adm inister m edication, it was observed t hat , in Hospit al 1, t he auxiliaries from t he day shift received m ore inform at ion from t he nurses, while auxiliaries from both shifts received inform ation from the nurse with continued education in Hospital 2.
DI SCUSSI ON
En v i r o n m e n t s f o r n u r si n g a ct i v i t i e s a r e indispensable in healt h inst it ut ions. Over t he years, m edicat ion pr epar at ion has been per for m ed in t he nursing service room which, due t o it s locat ion next t o t h e n u r si n g st a t i o n , r e ce i v e s t h e sa m e denom inat ion.
Cur r ent st andar ds r ecom m end one nur sing st at ion for every 30 beds, and a service room of at least 5.7 m ² for every st at ion( 4) . The service room s
at t he st udy hospit als exceeded t hese recom m ended dim ensions.
Reg ar d in g t h e illu m in at ion of t h e n u r sin g ser v ice r oom , it m ust be sufficient t o facilit at e t he reading of the prescription and the preparation of the m edication. Literature indicates that, when the source of illum inat ion is nat ural, direct incidence of sunlight m u st b e av oid ed , p r ev en t in g d et er ior at ion of t h e drug( 5). The nursing service room is considered part
of t he environm ent t hat needs art ificial illum inat ion, especially at night . I n cases of art ificial illum inat ion, t he use of fluor escent lam ps is r ecom m ended, in a quant it y com pat ible wit h t he dim ensions of t he room an d act iv it y per f or m ed, w h ich m u st be calcu lat ed accor dingly( 5 - 6 ). The illum inat ion in Hospit al 2 w as
consider ed insufficient .
acclim at izat ion of t he environm ent m ust be chosen. Therefore, t he use of a ceiling fan, found at Hospit al 2, is counter- indicated. According to the Determ ination by Collegiat e Dir ect or y ( RDC) nº 45, env ir onm ent s for m edication preparation, especially sm all and large volum es of parenteral solutions, m ust be free of dust and part icles( 4- 5).
Tracing a parallel between the environm ental conditions where all m edication is prepared, especially small and large volumes of parenteral solutions, and the RDC nº 45 recommendation: this environm ent should be of r est r ict ed access and ex clusiv e use, fr ee of dust ,
part icles and prot ect ed against t he ent rance of insect s
and guaranteeing sterility of the m edication, it is perceived t hat t he nursing service room s, neit her at t he st udy hospitals nor at other Brazilian public and private hospitals, do not comply with these recommendations. Awareness should be raised am ong service m anagers t o achieve compliance with this standard.
Th e r e i s p l e n t y o f d i scu ssi o n a b o u t t h e condit ions of m edicat ion pr epar at ion env ir onm ent s, r egar ding t he st er ilit y of t he pr epar ed m edicat ion. Som e au t h or s su g g est t h at , t o com p ly w it h leg al r ecom m en dat ion s( 5 ), par en t er al solu t ion s m u st be
prepared under a lam inar flow cabinet and, therefore, t heir preparat ion m ust be carried out by t he hospit al pharm acy in individual doses. On the other hand, it is known that m edication preparation in these conditions raises cost s, since it requires appropriat e equipm ent s and m ore personnel( 6).
Regarding the organization of the work space, it has been t he nur se’s dut y t o adequat e fur nit ur e and equipm ent s t o t he dev eloped act iv it ies. Nur se leaders at t heir unit s m ust st udy t he dim ensions of cabin et s an d dr aw er s design at ed f or con su m pt ion m a t e r i a l , so a s t o g i v e p r o f e ssi o n a l s f a st a n d er gonom ic access.
The existence of nursing service organization st an d ar d s g u id es t h e act iv it ies. Th ese st an d ar d s d et er m i n e a ct i v i t i es o r g u i d e t h e d escr i p t i o n o f adm inist r at iv e or t echnical act ions in t he scope of nur sing act iv it ies( 7). I n t his per spect iv e, t he st udy
inst it ut ions are not organized in t erm s of m edicat ion conser v at ion st andar ds, neit her under r efr iger at ion nor in am bient t em perat ure.
One of the suggestions presented is that the services can choose to execute standards and routines adj usted to the actual situation of the em ployees who are in charge of activities( 7). I n this sense, the service
h e a d s a t t h e st u d y h o sp i t a l s m u st u se t h e se
inst r um ent s t o assur e t he unifor m it y of m edicat ion pr ocedur es, r anging fr om st or age and conser v at ion t o preparat ion and adm inist rat ion.
Concerning the availability of trays and basins to support m edication preparation and transportation, it is necessary to estim ate the num ber of tim es these m aterials are used during the day m ust be estim ated( 8).
The reason is t hat t hese m at erials seem insufficient at the units, considering that they are used for other nur sing pr ocedur es.
The infusion pum ps ident ified at t he st udy sites are in conform ity with legislation and the available quant it y at t ends t o t he sect or’s needs.
With regards to m aterial and equipm ent, their availability in due tim e and quantity allow for activities to be perform ed without any harm to the patient.
To p r e p a r e o r a l m e d i ca t i o n , l i t e r a t u r e indicat es t he use of disposable cups, especially t o a d m i n i st e r sy r u p s, su sp e n si o n s a n d e m u l si o n s. Likewise, the use of a m ortar is indicated to triturate drugs for adm inistration by nasogastric or nasoenteral probes( 9- 10).
Only Hospital 2 has disposable cups available for or al m edicat ion adm inist r at ion and a m or t ar t o t r it u r at e pills. At Hospit al 1 , sy r in ges ar e u sed t o m easure, dissolve and transport liquid drugs. This form of st orage favors errors, as it facilit at es a change in adm inist rat ion rout e.
Anot her aspect in t he m at erial available for m ed icat ion p r ep ar at ion w as st an d ar d izat ion . Th e st andardizat ion of m at erial allows for good econom ic and technical results and m ainly supports the m aterial prevision process by reducing t he num ber of it em s, t u r n i n g m a t e r i a l o r g a n i za t i o n a n d co n t r o l m o r e efficient( 11). I t is agreed that standardization sim plifies
and reduces waste. On the other hand, it is im portant for st andar dized elem ent s t o be car efully analyzed, so as not to cause any risk to the patient.
Am ong ot her considerat ions, t he non- observance of this aspect in choosing syringes and needles constitutes a pot ent ial com plicat ion in int ram uscular inj ect ions(
9-10,12). Therefore, a review of this item is recom m ended,
considering variat ions in t he age range and physical com plexion of patients attended at m edical clinics.
Scalp ( but t er fly ) dev ices and cat het er s for venipuncture (j elco/ abbocat h) are available in several
calibers, allowing for a choice based on an evaluation of t he pat ient ’s venous syst em .
To identify the m edication to be adm inistered, it is the institution’s role to determ ine and attend this safet y need in m edicat ion t herapy. For t his purpose, ad h esiv e t ap e is in d icat ed( 9 ). I n t h is case, eit h er gum m ed tape or m arker pens can be used, according t o inst it ut ional st andards.
To analyze the adequacy of the nursing staff, so m e r e q u i r e m e n t s a r e i m p o r t a n t , su ch a s t h e adopt ed calculat ion m et hod and t he per cent age of professionals, according t o t he pat ient s’ classificat ion system . I n term s of staff quantity, we found the m ost crit ical personnel sit uat ion at Hospit al 2.
What staff dim ensioning in teaching hospitals is concerned, it m ust also be considered that the transit of facult y and st udent s int erfere wit h care dynam ics. This requires at t ent ion in calculat ions of professional absence rat es( 13).
I n t e r m s o f p u b l i c h o sp i t a l s, t h e p o l i cy regarding the adm ission of hum an resource adm ission policies ar e link ed up w it h higher polit ical decision lev els, as t h is pr ocess occu r s by m ean s of pu blic exam s or t hrough t em porary cont ract s by t he St at e Healt h Secr et ar y.
Pr o f essi o n a l t r a i n i n g h a s b een t h e m o st e f f e ct i v e w a y t o p r e p a r e t h e m t o co p e w i t h t echnological and scient ific changes t hat are invading
t he hospit al inst it ut ions( 1 4 ). I n m edicat ion t her apy, p r o f e ssi o n a l e d u ca t i o n m u st a d d r e ss n o t o n l y in n ov at ion s in t er m s of m edicat ion adm in ist r at ion suppor t equipm ent , in t his case sev er al m odels of infusion pum ps. Updat es about m edicat ion gr oups, t heir effect s and possible r eact ions ar e essent ial t o m onit or pat ient s r eceiv ing m edicat ion t herapy. ar e institutionseen the m ost effective way to prepare them t o t he coping of t echnological and scie.
FI NAL CONSI DERATI ONS
At the end of this study, we could characterize the m edication preparation structure and the m ultiple r elat ed f act or s t h at in t er f er e w it h t h e q u alit y of m edicat ion t h er apy at t h e st u dy in st it u t ion s. Th e m edicat ion preparat ion environm ent did not com ply w i t h cu r r en t l e g i sl a t i o n , r eq u i r i n g i m m e d i a t e m odificat ions. The availabilit y of m at er ial r esour ces for m edication preparation also needs to be revised in t erm s of quant it y of syringes and m ainly hypoderm ic needles st andar dized by t he inst it ut ions. Under t he current circum stances, these offer risks to the patients. The result s show t hat nursing professionals d o n ot r eceiv e in f or m at ion ab ou t t h e sy st em at ic handling of infusion pum ps and m edication. Allied with the lack of standards, routines and procedures related to m edication conservation and storage, this threatens care qualit y.
Finally, the structure of the m edication system is essent ial t o obt ain a safe and effect ive m edicat ion t herapy. The fact ors appoint ed in t his st udy int erfere w i t h t h e m e d i ca t i o n a d m i n i st r a t i o n p r o ce ss. Consequent ly, m odificat ions are required t o achieve high- qualit y m edicat ion t herapy.
REFERENCES
1. Nogueira LCL. Gerenciando pela qualidade t ot al na saúde. 3ª ed. Belo Horizont e ( MG) : Desenvolvim ent o; 2003. 2. Donabedian A. The definit ion of qualit y and approaches t o i t s a sse ssm e n t : An n Ar b o r. Mi ch i g a n ( USA) : H e a l t h Adm in ist r at ion Pr ess; 1 9 8 0 .
3. Paganini JM. Calidad Y eficiencia de la atención hospitalaria: la relación entre estructura, proceso y resultado. Washington DC. ( USA) : Organización Panam ericana de la Salud; 1993. 4. Minist ério da Saúde ( BR) . Resolução RDC n° 50, de 21 de fevereiro de 2002. Dispõe sobre o Regulam ento Técnico para p lan ej am en t o, p r og r am ação, elab or ação e av aliação d e proj et os físicos de est abelecim ent os assist enciais de saúde. Diário Oficial da República Federat iva do Brasil. Brasília ( DF) : Minist ério da Saúde; 2002.
5. Minist ério da Saúde ( BR) . Resolução RDC n° 45, de 12 de m arço de 2003. Dispõe sobre Regulam ent o Técnico de Boas Prát icas de Ut ilização das Soluções Parent erais. Diário Oficial da República Feder at iva do Br asil. Br asília ( DF) : Minist ér io da Saúde; 2003.
6. Usber co LMP, Gast aldi SR; Sant os GAA; Fer nandes AT; Rib eir o Filh o N. Far m ácia Hosp it alar. I n : Fer n an d es AT; Fe r n a n d e s MOV, e d i t o r e s. I n f e cçã o H o sp i t a l a r e su a s I nt erfaces na Área da Saúde. São Paulo ( SP) : Edit ora At heneu; 2 0 0 0 .
7 . Si l v a VEF. Man u ai s d e En f er m ag em . I n : Ku r cg an t P, organizador. Adm inist ração em Enferm agem . São Paulo ( SP) : EPU; 1 9 9 1 .
Recebido em : 16.12.2005 Aprovado em : 21.11.2006
9. Giov ani AMM. Enfer m agem : cálculo e adm inist r ação de m edicam ent os. São Paulo ( SP) : Legnar I nform át ica Edit ora; 1 9 9 9 .
10. Adm inist r ação de Medicam ent os. Rio de Janeir o ( RJ) : Reichm ann & Affonso Edit ores; 2002.
1 1 . Cast ilh o V, Gon çalves VLM. Adm in ist r ação de r ecu r sos m at er iais em en f er m ag em : I n : Ku r cg an t P, or g an izad or. Ge r e n ci a m e n t o e m En f e r m a g e m . Ri o d e Ja n e i r o ( RJ) : Guanabara Koogan; 2005.
1 2 . Fi g u e i r e d o NMA. Ad m i n i st r a çã o d e m e d i ca m e n t o s: r ev isan d o u m a p r át ica d e en f er m ag em . São Pau lo ( SP) : Difusão Paulist a de Enferm agem Edit ora; 2001.
13. Ant unes AV; Cost a MN. Dim ensionam ent o de pessoal de enfer m agem em um hospit al univ er sit ár io. Rev Lat ino- am Enfer m agem 2003 dezem br o; 11( 6) : 832- 9.
