Selbst S M, Fein J A, Osterhoudt K, Ho W
Division of Emergency Medicine, the Children's Hospital of Philadelphia, and University of Pennsylvania School of Medicine, USA.
Pediatr Emerg Care. 1999 Feb;15(1):1-4. doi: 10.1097/00006565-199902000-00001.
To initiate investigation into the medication errors that occur in a pediatric emergency department. These errors have the potential for significant morbidity and mortality, as well as costly litigation.
We conducted a retrospective chart review of all medication and intravenous fluid errors identified in a pediatric emergency department through incident reports filed over a 5-year period. An attempt was made to determine who was involved with the errors and what caused the errors. The patient outcomes were noted and classified according to clinical significance using previously published criteria.
Thirty-three incident reports involving medication or intravenous fluid errors were analyzed. Most errors occurred on the evening and night shifts. Nurses were involved in 39% of reported errors; the nurse and emergency physician were jointly involved in 36%. The most common error was an incorrect dose of medication (35%) or incorrect medication given (30%). In one third of the cases, the family was not made aware of the error. In 12%, patients required additional treatment, and one was admitted to the hospital because of the error. There were no deaths.
Incorrect recording of patient weights leading to an incorrect medication dose and failure to note drug allergy are common causes for medication errors in the pediatric emergency department. Incorrect drugs and i.v. fluids are given because of similar names and packaging. Many of the errors in the ED seem to be preventable.
对儿科急诊科发生的用药错误展开调查。这些错误有可能导致严重的发病率和死亡率，以及代价高昂的诉讼。
我们对通过5年期间提交的事件报告所确定的儿科急诊科所有用药和静脉输液错误进行了回顾性病历审查。试图确定哪些人涉及这些错误以及错误的成因。记录患者的结局，并根据先前公布的标准按临床意义进行分类。
分析了33份涉及用药或静脉输液错误的事件报告。大多数错误发生在晚班和夜班。护士涉及39%的报告错误；护士和急诊医生共同涉及36%。最常见的错误是用药剂量错误（35%）或用药错误（30%）。在三分之一的病例中，家属未被告知错误。12%的患者需要额外治疗，1名患者因该错误入院。无死亡病例。
患者体重记录错误导致用药剂量错误以及未注意药物过敏是儿科急诊科用药错误的常见原因。因药品名称和包装相似而导致用药和静脉输液错误。急诊科的许多错误似乎是可以预防的。
