Gurwitz Jerry H, Field Terry S, Radford Martha J, Harrold Leslie R, Becker Richard, Reed George, DeBellis Kristin, Moldoff Jason, Verzier Nancy
Meyers Primary Care Institute, University of Massachusetts Medical School, Fallon Clinic Foundation, and Fallon Community Health Plan, Worcester, Mass 01605, USA.
Am J Med. 2007 Jun;120(6):539-44. doi: 10.1016/j.amjmed.2006.07.045. Epub 2007 Apr 26.
We examined the preventability of adverse warfarin-related events and potential adverse warfarin-related events ("near misses") in the nursing home setting.
We performed a cohort study of all long-term care residents of 25 nursing homes (bed size range, 90-360) in Connecticut during a 12-month observation period. The total number of residents in these facilities ranged from 2946 to 3212 per quarter. There were 490 residents who received warfarin therapy. Possible warfarin-related incidents were detected by quarterly retrospective review of nursing home records by trained nurse abstractors. Each incident was independently classified by 2 physician-reviewers to determine whether it constituted a warfarin-related event, its severity, and its preventability. The primary outcome was an adverse warfarin-related event, defined as an injury associated with the use of warfarin. Potential adverse warfarin-related events were defined as situations in which the international normalized ratio (INR) was noted to be 4.5 or greater, an error in management was noted, but no injury occurred. We also assessed time in specified INR ranges per nursing home resident day on warfarin.
Over the 12-month observation period, 720 adverse warfarin-related events and 253 potential adverse warfarin-related events were identified. Of the adverse warfarin-related events, 625 (87%) were characterized as minor, 82 (11%) were deemed serious, and 13 (2%) were life-threatening or fatal. Overall, 29% of the adverse warfarin-related events were judged to be preventable. Serious, life-threatening, or fatal events occurred at a rate of 2.49 per 100 resident-months; 57% of these more severe events were considered preventable. Errors resulting in preventable events occurred most often at the prescribing and monitoring stages of warfarin management. The percentages of time in the less than 2, 2 to 3, and more than 3 INR ranges were 36.5%, 49.6%, and 13.9%, respectively.
The use of warfarin in the nursing home setting presents substantial safety concerns for patients. Adverse events associated with warfarin therapy are common and often preventable in the nursing home setting. Prevention strategies should target the prescribing and monitoring stages of warfarin management.
我们研究了在养老院环境中与华法林相关的不良事件及潜在不良事件（“未遂事件”）的可预防性。
我们对康涅狄格州25家养老院（床位规模在90至360张之间）的所有长期护理居民进行了一项队列研究，观察期为12个月。这些机构每季度的居民总数在2946至3212人之间。有490名居民接受了华法林治疗。经过培训的护士摘要员通过对养老院记录进行季度回顾性审查来发现可能与华法林相关的事件。每起事件由两名医生审核员独立分类，以确定其是否构成与华法林相关的事件、严重程度及其可预防性。主要结局是与华法林相关的不良事件，定义为与使用华法林相关的损伤。潜在的与华法林相关的不良事件定义为国际标准化比值（INR）达到或超过4.5、管理出现错误但未发生损伤的情况。我们还评估了每位接受华法林治疗的养老院居民在特定INR范围内的时间。
在12个月的观察期内，共识别出720起与华法林相关的不良事件和253起潜在的与华法林相关的不良事件。在与华法林相关的不良事件中，625起（87%）为轻微事件，82起（11%）被视为严重事件，13起（2%）为危及生命或致命事件。总体而言，29%的与华法林相关的不良事件被判定为可预防。严重、危及生命或致命事件的发生率为每100居民月2.49起；这些更严重事件中有57%被认为是可预防的。导致可预防事件的错误最常发生在华法林管理的处方和监测阶段。INR小于2、2至3以及大于3的时间百分比分别为36.5%、49.6%和13.9%。
在养老院环境中使用华法林给患者带来了重大安全问题。与华法林治疗相关的不良事件很常见，且在养老院环境中往往是可预防的。预防策略应针对华法林管理的处方和监测阶段。
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