Wong Ian C K, Ghaleb Maisoon A, Franklin Bryony D, Barber Nick
Centre for Paediatric Pharmacy Research, The School of Pharmacy, University of London & the Institute of Child Health, University College London, London, UK.
Drug Saf. 2004;27(9):661-70. doi: 10.2165/00002018-200427090-00004.
In paediatric medicine, drug doses are usually calculated individually based on the patient's age, weight and clinical condition. Therefore, there are increased opportunities for, and a relatively high risk of, dosing errors in this setting. Consequently, a systematic literature review using several databases was conducted to investigate the incidence and nature of dosing errors in children; 16 studies were found to be relevant. Eleven of the 16 studies found that dosing errors are the most common type of medication error, three of the remaining studies found it to be the second most common type. This review of published research on medication errors therefore suggests that dosing errors are probably the most common type of error in the paediatric population. In addition, there was a great variation in the error rates reported; this is likely to be due to the differences in the medication error definitions and methodologies employed. For example, the dosing error rate determined using spontaneous reporting ranges from 0.03 per 100 admissions in the UK to 2 per 100 admissions in the US. Extrapolating this, if the under-reporting rate is about 1 in 100, then the true incidence would be around 50,000 paediatric dosing errors per year in England. The information available shows that dosing errors are not uncommon and that 10-fold overdoses caused by calculation errors have led to serious consequences. There is an urgent need to develop methods to reduce medication errors in children and dosing errors should be the first priority.
在儿科医学中，药物剂量通常根据患者的年龄、体重和临床状况进行个体化计算。因此，在这种情况下，出现给药错误的机会增加，且风险相对较高。因此，我们使用多个数据库进行了一项系统的文献综述，以调查儿童给药错误的发生率和性质；共找到16项相关研究。16项研究中的11项发现给药错误是最常见的用药错误类型，其余3项研究发现它是第二常见的类型。因此，这项对已发表的用药错误研究的综述表明，给药错误可能是儿科人群中最常见的错误类型。此外，报告的错误率存在很大差异；这可能是由于所采用的用药错误定义和方法不同所致。例如，使用自发报告确定的给药错误率在英国为每100例入院患者0.03例，在美国为每100例入院患者2例。由此推断，如果漏报率约为1%，那么在英格兰，每年真正的儿科给药错误发生率约为50000例。现有信息表明，给药错误并不罕见，由计算错误导致的10倍过量用药已造成严重后果。迫切需要开发减少儿童用药错误的方法，给药错误应成为首要重点。
