van den Bemt Patricia M L A, Fijn Roel, van der Voort Peter H J, Gossen Annet A, Egberts Toine C G, Brouwers Jacobus R B J
Hospital Pharmacy Midden-Brabant, The Netherlands.
Crit Care Med. 2002 Apr;30(4):846-50. doi: 10.1097/00003246-200204000-00022.
The study aimed to identify both the frequency and the determinants of drug administration errors in the intensive care unit.
Administration errors were detected by using the disguised-observation technique (observation of medication administrations by nurses, without revealing the aim of this observation to the nurses).
Two Dutch hospitals.
The drug administrations to patients in the intensive care units of two Dutch hospitals were observed during five consecutive days.
None.
A total of 233 medications for 24 patients were observed to be administered (whether ordered or not) or were observed to be omitted. When wrong time errors were included, 104 administrations with at least one error were observed (frequency, 44.6%), and when they were excluded, 77 administrations with at least one error were observed (frequency, 33.0%). When we included wrong time errors, day of the week (Monday, odds ratio [OR] 2.69, confidence interval [CI] 1.42-5.10), time of day (6-10 pm, OR 0.28, CI 0.10-0.78), and drug class (gastrointestinal, OR 2.94, CI 1.48-5.85; blood, OR 0.12, CI 0.03-0.54; and cardiovascular, OR 0.38, CI,0.16-0.90) were associated with the occurrence of errors. When we excluded wrong time errors, day of the week (Monday, OR 3.14, CI 1.66-5.94), drug class (gastrointestinal, OR 3.47, CI 1.76-6.82; blood, OR 0.21, CI 0.05-0.91; and respiratory, OR 0.22, CI 0.08-0.60), and route of administration (oral by gastric tube, OR 5.60, CI 1.70-18.49) were associated with the occurrence of errors. In the hospital without full-time specialized intensive care physicians (which also lacks pharmacy-provided protocols for the preparation of parenteral drugs), more administration errors occurred, both when we included (OR 5.45, CI 3.04-9.78) and excluded wrong time errors (OR 4.22, CI 2.36-7.54).
Efforts to reduce drug administration errors in the intensive care unit should be aimed at the risk factors we identified in this study. Especially, focusing on system differences between the two intensive care units (e.g., presence or absence of full-time specialized intensive care physicians, presence or absence of protocols for the preparation of all parenteral drugs) may help reduce suboptimal drug administration.
本研究旨在确定重症监护病房给药错误的发生率及其决定因素。
采用隐蔽观察技术（护士观察药物给药情况，但不向护士透露该观察目的）来检测给药错误。
两家荷兰医院。
连续五天观察了两家荷兰医院重症监护病房内患者的药物给药情况（无论是否有医嘱），同时也观察了药物遗漏情况。
无。
共观察了24例患者的233次药物给药（无论是否有医嘱）或药物遗漏情况。若将给药时间错误计算在内，观察到104次给药存在至少一处错误（发生率为44.6%）；若排除给药时间错误，则观察到77次给药存在至少一处错误（发生率为33.0%）。若将给药时间错误计算在内，一周中的日期（周一，比值比[OR]为2.69，置信区间[CI]为1.42 - 5.10）、一天中的时间（下午6点至10点，OR为0.28，CI为0.10 - 0.78）以及药物类别（胃肠道药物，OR为2.94，CI为1.48 - 5.85；血液系统药物，OR为0.12，CI为0.03 - 0.54；心血管系统药物，OR为0.38，CI为0.16 - 0.90）与错误的发生相关。若排除给药时间错误，一周中的日期（周一，OR为3.14，CI为1.66 - 5.94）、药物类别（胃肠道药物，OR为3.47，CI为1.76 - 6.82；血液系统药物，OR为0.21，CI为0.05 - 0.91；呼吸系统药物，OR为0.22，CI为0.08 - 0.60）以及给药途径（经胃管口服，OR为5.60，CI为1.70 - 18.49）与错误的发生相关。在没有全职专科重症监护医生的医院（该医院也缺乏药房提供的肠外药物配制方案），无论是否将给药时间错误计算在内，给药错误都更多（计算在内时，OR为5.45，CI为3.04 - 9.78；排除给药时间错误时，OR为4.22，CI为2.36 - 7.54）。
降低重症监护病房给药错误的努力应针对本研究中确定的危险因素。特别是，关注两个重症监护病房之间的系统差异（例如，是否有全职专科重症监护医生、是否有所有肠外药物的配制方案）可能有助于减少不理想的药物给药情况。
