Stubbs Jean, Haw Camilla, Taylor David
St Andrew's Hospital, Northampton, UK.
J Psychopharmacol. 2006 Jul;20(4):553-61. doi: 10.1177/0269881106059808. Epub 2006 Jan 9.
Medication errors are an important cause of patient morbidity and mortality, of which there have been few reports in psychiatry, especially in the UK. Our aim was to examine the nature, frequency and potential severity of prescribing errors in UK mental health units in a prospective, 1 week survey of errors detected by pharmacy staff in nine NHS trusts. Pharmacists checked 22036 prescription items. In total, 523 errors meeting the study definition were detected (2.4% of prescription items checked). Prescription writing errors (77.4%) were most common, while decision-making errors accounted for 22.6% of errors. In 280 (53.5%) cases the prescribed drug had been administered before the error was detected. Most errors were of doubtful or minor importance but 22 (4.3%) were deemed likely to result in serious adverse effects or death. The error detection rate varied fourfold between trusts. Prescribing errors are fairly common in psychiatry. A small proportion of errors have the potential for serious harm. Pharmacy staff have an important role to play in their management.
用药错误是导致患者发病和死亡的一个重要原因，然而在精神病学领域，尤其是在英国，关于用药错误的报告却很少。我们的目的是通过对9个国民保健服务信托机构药房工作人员在为期1周的前瞻性调查中发现的错误进行研究，来审视英国精神卫生机构中处方错误的性质、频率及潜在严重性。药剂师检查了22036张处方。总共检测到523例符合研究定义的错误（占所检查处方的2.4%）。处方书写错误最为常见（77.4%），而决策错误占错误总数的22.6%。在280例（53.5%）病例中，错误被发现之前已使用了所开药物。大多数错误的重要性存疑或较小，但有22例（4.3%）被认为可能导致严重不良反应或死亡。各信托机构之间的错误检出率相差四倍。处方错误在精神病学领域相当常见。一小部分错误有可能造成严重伤害。药房工作人员在管理这些错误方面可发挥重要作用。
