Dibbi Huda M, Al-Abrashy Hanan F, Hussain Waleed A, Fatani Mohammad I, Karima Talal M
Department of Pharmacy, Hera General Hospital, PO Box 2028, Makkah, Kingdom of Saudi Arabia.
Saudi Med J. 2006 Oct;27(10):1489-92.
To develop better understanding of Medication Errors (MEs) in the health care sector, and to improve the error prevention services in the hospital.
We conducted a retrospective study at the Hera General Hospital, Makkah, Saudi Arabia. The medical records were reviewed for adult hospitalized patients from June 1, 2000 to June 30, 2002. Patients demographic data, types, and causes of MEs, were recorded. The contributing factors, frequency and patient's outcome were also analyzed.
A total of 2627 patient files were analyzed, 3963 errors were studied as follows: 1559 files contain one error, 800 files with 2 errors, and 268 with >3 errors. The most common type of error found was wrong strength (concentration) in 914 patients (34.79%), 807 patients (30.7%) had wrong route of administration, and 788 (30%) had wrong dosage form. On the other hand, the most common cause identified for MEs, was human factor, which accounted in 1223 patients (46.49%). Miscommunication was the most common second cause in 920 patients (35.02%), and the third common cause was name confusion [484, (18.43%)]. Medication Errors were classified from a regulatory prospective into actual in 735 patient files (28%), potential in 1866 (71%) and serious in 26 (0.98%).
The study showed that wrong strength was the most common ME found and human factors were the most common cause contributing MEs. Therefore, focusing on these factors will definitely minimize MEs in hospitalized patients.
更好地了解医疗保健领域的用药错误（MEs），并改善医院的差错预防服务。
我们在沙特阿拉伯麦加的赫拉综合医院进行了一项回顾性研究。对2000年6月1日至2002年6月30日期间成年住院患者的病历进行了审查。记录了患者的人口统计学数据、用药错误的类型和原因。还分析了促成因素、频率和患者的结局。
共分析了2627份患者档案，研究了3963起错误，具体如下：1559份档案包含1起错误，800份档案有2起错误，268份档案有超过3起错误。发现最常见的错误类型是浓度错误（强度），有914名患者（34.79%）；807名患者（30.7%）给药途径错误；788名患者（30%）剂型错误。另一方面，确定的用药错误最常见原因是人为因素，有1223名患者（46.49%）。沟通失误是第二常见原因，有920名患者（35.02%），第三常见原因是名称混淆[484名患者，（18.43%）]。从监管角度将用药错误分为实际错误的有735份患者档案（28%），潜在错误的有1866份（71%），严重错误的有26份（0.98%）。
研究表明，浓度错误是发现的最常见用药错误，人为因素是导致用药错误的最常见原因。因此，关注这些因素肯定会减少住院患者的用药错误。
