Ross L M, Wallace J, Paton J Y
Department of Child Health, University of Glasgow, Royal Hospital for Sick Children, Yorkhill NHS Trust, Glasgow G3 8SJ, UK.
Arch Dis Child. 2000 Dec;83(6):492-7. doi: 10.1136/adc.83.6.492.
In the past 10 years, medication errors have come to be recognised as an important cause of iatrogenic disease in hospital patients.
To determine the incidence and type of medication errors in a large UK paediatric hospital over a five year period, and to ascertain whether any error prevention programmes had influenced error occurrence.
Retrospective review of medication errors documented in standard reporting forms completed prospectively from April 1994 to August 1999. Main outcome measure was incidence of error reporting, including pre- and post-interventions.
Medication errors occurred in 0.15% of admissions (195 errors; one per 662 admissions). While the highest rate occurred in neonatal intensive care (0.98%), most errors occurred in medical wards. Nurses were responsible for most reported errors (59%). Errors involving the intravenous route were commonest (56%), with antibiotics being the most frequent drug involved (44%). Fifteen (8%) involved a tenfold medication error. Although 18 (9.2%) required active patient intervention, 96% of errors were classified as minor at the time of reporting. Forty eight per cent of parents were not told an error had occurred. The introduction of a policy of double checking all drugs dispensed by pharmacy staff led to a reduction in errors from 9.8 to 6 per year. Changing the error reporting form to make it less punitive increased the error reporting rate from 32.7 to 38 per year.
The overall medication error rate was low. Despite this there are clear opportunities to make system changes to reduce error rates further.
在过去10年中，用药错误已被公认为医院患者医源性疾病的一个重要原因。
确定一家大型英国儿科医院在5年期间用药错误的发生率和类型，并确定任何错误预防计划是否对错误发生有影响。
回顾性审查1994年4月至1999年8月前瞻性填写在标准报告表中的用药错误。主要结局指标是错误报告的发生率，包括干预前后。
用药错误发生在0.15%的入院病例中（195例错误；每662例入院中有1例）。虽然最高发生率出现在新生儿重症监护室（0.98%），但大多数错误发生在内科病房。护士对大多数报告的错误负责（59%）。涉及静脉途径的错误最常见（56%），抗生素是最常涉及的药物（44%）。15例（8%）涉及10倍剂量的用药错误。虽然18例（9.2%）需要对患者进行积极干预，但96%的错误在报告时被归类为轻微错误。48%的家长未被告知发生了错误。引入药房工作人员对所有配发药物进行双重核对的政策后，错误从每年9.8例减少到6例。将错误报告表改为不那么具有惩罚性的形式，使错误报告率从每年32.7例增加到38例。
总体用药错误率较低。尽管如此，仍有明显机会进行系统变革以进一步降低错误率。
