Gurwitz J H, Field T S, Avorn J, McCormick D, Jain S, Eckler M, Benser M, Edmondson A C, Bates D W
Meyers Primary Care Institute, the Fallon Healthcare System, and the University of Massachusetts Medical School (JHG, TSF, DM, SJ, ME, MB), Worcester, Massachusetts, USA.
Am J Med. 2000 Aug 1;109(2):87-94. doi: 10.1016/s0002-9343(00)00451-4.
Adverse drug events, especially those that may have been preventable, are among the most serious concerns about medication use in nursing homes. We studied the incidence and preventability of adverse drug events and potential adverse drug events in nursing homes.
We performed a cohort study of all long-term care residents of 18 community-based nursing homes in Massachusetts during a 12-month observation period. Potential drug-related incidents were detected by stimulated self-report by nursing home staff and by periodic review of the records of nursing home residents by trained nurse and pharmacist investigators. Each incident was classified by 2 independent physician-reviewers, using a structured implicit review process, by whether or not it constituted an adverse drug event or potential adverse drug event (those that may have caused harm, but did not because of chance or because they were detected), by the severity of the event (significant, serious, life-threatening, or fatal), and by whether it was preventable. Examples of significant events included nonurticarial rashes, falls without associated fracture, hemorrhage not requiring transfusion or hospitalization, and oversedation; examples of serious events included urticaria, falls with fracture, hemorrhage requiring transfusion or hospitalization, and delirium.
During 28,839 nursing home resident-months of observation in the 18 participating nursing homes, 546 adverse drug events (1.89 per 100 resident-months) and 188 potential adverse drug events (0.65 per 100 resident-months) were identified. Of the adverse drug events, 1 was fatal, 31 (6%) were life-threatening, 206 (38%) were serious, and 308 (56%) were significant. Overall, 51% of the adverse drug events were judged to be preventable, including 171 (72%) of the 238 fatal, life-threatening, or serious events and 105 (34%) of the 308 significant events (P < 0.001). Errors resulting in preventable adverse drug events occurred most often at the stages of ordering and monitoring; errors in transcription, dispensing, and administration were less commonly identified. Psychoactive medications (antipsychotics, antidepressants, and sedatives/hypnotics) and anticoagulants were the most common medications associated with preventable adverse drug events. Neuropsychiatric events were the most common types of preventable adverse drug events.
Adverse drug events are common and often preventable in nursing homes. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the ordering and monitoring stages of pharmaceutical care.
药物不良事件，尤其是那些可能本可预防的事件，是养老院用药方面最严重的问题之一。我们研究了养老院中药物不良事件及潜在药物不良事件的发生率和可预防性。
我们对马萨诸塞州18家社区养老院的所有长期护理居民进行了一项队列研究，观察期为12个月。通过养老院工作人员激发式自我报告以及由经过培训的护士和药剂师调查员定期审查养老院居民记录来检测潜在的药物相关事件。每起事件由2名独立的医生审查员使用结构化的隐式审查流程进行分类，判断其是否构成药物不良事件或潜在药物不良事件（那些可能造成伤害，但因偶然因素或被发现而未造成伤害的事件）、事件的严重程度（显著、严重、危及生命或致命）以及是否可预防。显著事件的例子包括非荨麻疹性皮疹、无相关骨折的跌倒、无需输血或住院治疗的出血以及过度镇静；严重事件的例子包括荨麻疹、伴有骨折的跌倒、需要输血或住院治疗的出血以及谵妄。
在18家参与研究的养老院中，对28839个居民月进行观察期间，共识别出546起药物不良事件（每100居民月1.89起）和188起潜在药物不良事件（每100居民月0.65起）。在药物不良事件中，1起是致命的，31起（6%）是危及生命的，206起（38%）是严重的，308起（56%）是显著的。总体而言，51%的药物不良事件被判定为可预防的，包括238起致命、危及生命或严重事件中的171起（72%）以及308起显著事件中的105起（34%）（P < 0.001）。导致可预防药物不良事件的错误最常发生在医嘱开具和监测阶段；转录、配药和给药方面的错误较少被发现。精神活性药物（抗精神病药、抗抑郁药和镇静催眠药）和抗凝剂是与可预防药物不良事件相关最常见的药物。神经精神事件是可预防药物不良事件最常见的类型。
药物不良事件在养老院中很常见且往往可预防。更严重的药物不良事件更有可能被预防。预防策略应针对药学服务的医嘱开具和监测阶段。
