Wirtz Veronika, Taxis Katja, Barber Nick D
Department of Practice and Policy, School of Pharmacy, University of London, UK.
Pharm World Sci. 2003 Jun;25(3):104-11. doi: 10.1023/a:1024009000113.
To investigate the incidence and the severity of intravenous (i.v.) drug preparation and administration errors in two countries and three pharmacy services.
A disguised observational method was used to record details of the preparation and administration of prescribed i.v. drugs on two wards in each of three teaching hospitals: one with a traditional British ward pharmacy service (TBP) and two hospitals in Germany, one with a traditional ward stock supply (TGP) and one with a satellite pharmacy service (GSP) with unit dose system.
Errors in i.v. drug preparation and administration and their potential significance.
The number of observed preparations/administrations were: TBP 77/63, TGP 126/109 and GSP 134/106. The preparation error rates were: TBP 22% (95% confidence interval: 13-31%), TGP 23% (16-30%) and GSP 31% (23-39%). The administration error rates were TBP 27% (16-38%), TGP 49% (39-58%) and GSP 22% (14-30%). The percentage of administration errors on the wards with TGP was statistically significantly higher than in the other two services. Common errors at the study sites with TBP and GSP were omissions. Wrong rate of administration occurred most frequently on the wards with TGP. The majority of errors were likely to be of 'moderate' to 'severe' outcome. Careful drug chart reading could possibly reduce omission errors on the wards with TBP. A change of the German nursing law ('Krankenpflegegesetz') to legally entitle nurses to administer i.v. drugs could probably result in better training, national guidelines and standards.
This study found a high rate of i.v. medication errors of moderate to severe significance. Changes in practice should be considered to make i.v. therapy safer for patients.
调查两个国家的三种药学服务中静脉注射（i.v.）药物配制和给药错误的发生率及严重程度。
采用隐蔽观察法记录三家教学医院中每个医院两个病房的处方静脉注射药物的配制和给药细节：一家采用传统英国病房药学服务（TBP），德国的两家医院，一家采用传统病房库存供应（TGP），另一家采用配备单剂量系统的卫星药房服务（GSP）。
静脉注射药物配制和给药中的错误及其潜在意义。
观察到的配制/给药次数分别为：TBP为77/63，TGP为126/109，GSP为134/106。配制错误率分别为：TBP 22%（95%置信区间：13 - 31%），TGP 23%（16 - 30%），GSP 31%（23 - 39%）。给药错误率分别为：TBP 27%（16 - 38%），TGP 49%（39 - 58%），GSP 22%（14 - 30%）。TGP病房的给药错误百分比在统计学上显著高于其他两种服务。TBP和GSP研究地点的常见错误是遗漏。给药错误率在TGP病房最为频繁。大多数错误可能导致“中度”至“严重”的后果。仔细阅读药物图表可能会减少TBP病房的遗漏错误。德国护理法（“Krankenpflegegesetz”）的修改，使护士有合法权利进行静脉注射给药，可能会带来更好的培训、国家指南和标准。
本研究发现静脉注射用药错误发生率较高，具有中度至严重的意义。应考虑改变实践做法，以使静脉注射治疗对患者更安全。
