Grasso Benjamin C, Rothschild Jeffrey M, Genest Robert, Bates David W
Institute for Self-Directed Care, Portland, Maine, USA.
Jt Comm J Qual Saf. 2003 Aug;29(8):391-400. doi: 10.1016/s1549-3741(03)29047-x.
Adverse drug events (ADEs) have been implicated as a cause of substantial morbidity and mortality. Psychiatrists have successfully characterized one category of ADE--adverse drug reactions (ADRs), which have been studied from a medication-specific psychopharmacology frame of reference. The literature on ADEs, both preventable and nonpreventable, was reviewed within the broader patient safety framework.
English-language studies involving ADEs and medication errors in psychiatry for 1996 through 2003 were identified on MEDLINE and by using a hand search of bibliographies.
Few reports on the incidence and characteristics of medication errors in psychiatric hospitals could be found. Psychiatrists may not be sufficiently aware of the harm caused by errors, methodological issues regarding error detection, the validity of reported medication error rates, and the challenge of creating a nonpunitive error-reporting culture. PREVENTION STRATEGIES: Application of a systems-oriented approach to ADE reduction and the promotion of a nonpunitive culture are essential. Clinical and pharmacy staff could monitor the literature for published reports of preventable adverse events and review those reports in multidisciplinary team meetings.
Psychiatry would benefit from learning about the terminology used in describing medication errors and ADEs. Relatively few data are available regarding the frequency and consequences of medication errors in psychiatry; more research is needed.
药物不良事件（ADEs）已被认为是导致大量发病和死亡的原因。精神科医生已成功界定了一类药物不良事件——药物不良反应（ADRs），并从特定药物的精神药理学参考框架对其进行了研究。在更广泛的患者安全框架内，对关于可预防和不可预防的药物不良事件的文献进行了综述。
通过检索MEDLINE以及手工查阅参考文献，确定了1996年至2003年期间涉及精神科药物不良事件和用药错误的英文研究。
关于精神病医院用药错误的发生率和特征的报告很少。精神科医生可能没有充分意识到错误所造成的危害、错误检测的方法学问题、所报告的用药错误率的有效性，以及营造无惩罚性错误报告文化的挑战。预防策略：采用以系统为导向的方法来减少药物不良事件并促进无惩罚性文化至关重要。临床和药房工作人员可以监测文献中已发表的可预防不良事件报告，并在多学科团队会议上对这些报告进行审查。
精神科将从了解描述用药错误和药物不良事件所使用的术语中受益。关于精神科用药错误的频率和后果的数据相对较少；需要更多的研究。
