van den Bemt P M L A, Robertz R, de Jong A L, van Roon E N, Leufkens H G M
Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmacoepidemiology & Pharmacotherapy, Utrectht University, Utrecht, and Hospital Pharmacy Midden-Brabant, TweeSteden Hospital, Tilburg, The Netherlands.
J Intellect Disabil Res. 2007 Jul;51(Pt 7):528-36. doi: 10.1111/j.1365-2788.2006.00919.x.
Medication errors can result in harm, unless barriers to prevent them are present. Drug administration errors are less likely to be prevented, because they occur in the last stage of the drug distribution process. This is especially the case in non-alert patients, as patients often form the final barrier to prevention of errors. Therefore, a study was set up aimed at identifying the frequency of drug administration errors and determinants for these errors in an institution for individuals with intellectual disability (ID).
This observational study ('disguised observation') was conducted within an institution in the Netherlands caring for 2500 individuals with ID and lasted from October to December 2004 with a case control design for identifying determinants for errors. The institution consists of both day care units and living units (providing full-time care), located in different towns. For the study, five units from different towns were selected. Within each study unit, the administration of drugs to patients was observed for 2 weeks. In total, 953 drug administrations to 46 patients (25 male, mean age 25.8 years, range 2-73 years) were observed.
With inclusion of wrong time errors, 242 administrations with at least one error were observed [frequency=242/953 (25.4%)] and with exclusion 213 administrations with at least one error were observed [frequency=213/953 (22.4%)]. Determinants associated with errors were routes of administration 'oral by feeding tube' (OR 189.66; 95% CI 46.16-779.24) and 'inhalation' (OR 9.98; 95% CI 4.78-20.80), the units 'adult full-time care' (OR 2.12; 95% CI 1.05-4.35) and 'children daytime care' (OR 10.80; 95% CI 4.43-26.29) and the absence of a distribution robot (OR 4.0; 95% CI 2.67-5.95). None of the identified errors were reported to the voluntary reporting system.
This study shows that administration errors in an institution for individuals with ID are common and that they are not formally reported to the voluntary reporting system. Furthermore, it identified some determinants that may be the focus for future improvements aimed to reduce error frequency.
除非存在预防措施，用药错误可能会造成伤害。给药错误不太容易预防，因为它们发生在药品分发过程的最后阶段。在无警觉的患者中尤其如此，因为患者往往是预防错误的最后一道屏障。因此，开展了一项研究，旨在确定一所智障人士机构中给药错误的发生率及其相关决定因素。
这项观察性研究（“伪装观察”）在荷兰一家照顾2500名智障人士的机构内进行，从2004年10月持续至12月，采用病例对照设计来确定错误的决定因素。该机构包括日托单位和生活单位（提供全职护理），分布在不同城镇。为进行研究，从不同城镇选取了五个单位。在每个研究单位中，对患者的给药情况进行了为期2周的观察。总共观察了对46名患者（25名男性，平均年龄25.8岁，年龄范围2至73岁）的953次给药。
若将给药时间错误包括在内，观察到242次给药至少存在一项错误[发生率=242/953（25.4%）]；若不包括给药时间错误，则观察到213次给药至少存在一项错误[发生率=213/953（22.4%）]。与错误相关的决定因素包括给药途径“经鼻饲管口服”（比值比189.66；95%置信区间46.16至779.24）和“吸入”（比值比9.98；95%置信区间4.78至20.80）、单位“成人全职护理”（比值比2.12；95%置信区间1.05至4.35）和“儿童日托”（比值比10.80；95%置信区间4.43至2,629）以及未配备分发机器人（比值比4.0；95%置信区间2.67至5.95）。所发现的错误均未上报至自愿报告系统。
本研究表明，智障人士机构中的给药错误很常见，且未正式上报至自愿报告系统。此外，研究还确定了一些可能成为未来旨在降低错误发生率改进措施重点的决定因素。
