Deters Michael, Prasa Dagmar, Hentschel Helmut, Schaper Andreas
Poisons Information Center, Erfurt, Germany.
Clin Toxicol (Phila). 2009 Feb;47(2):169-73. doi: 10.1080/15563650701781931.
We investigated the iatrogenic intravenous medication errors (IIME) reported to the Poisons Information Center (PIC) Erfurt.
All IIME over a ten year period were analyzed retrospectively and categorized into error types, age groups, drugs involved, and estimated risk of toxicity.
From 1997 to 2006 the PIC Erfurt registered 132 cases of IIME. They increased from 7 in 1997 to 31 in 2006. Children accounted for 31.1% of the patients affected and adults for 68.9%. The drug classes (ATC classification) involved most frequently were antipsychotics (9.8%) and antihistamines for systemic use (7.5%). The main types of IIME were overdose (53.1%) and incorrect route of administration (29.7%). The estimated risk of toxicity was: 14.4% none, 71.2% risk of toxicity, and 14.4% unpredictable risk. Medical treatment was recommended in 82%. The outcome of 104 of the 132 (78.8%) courses was unknown. In the 28 cases followed to a known outcome, 9 (32%) were asymptomatic and 19 (68%) symptomatic with minor (9 cases), moderate (1 case), and severe features (6 cases) but mostly complete recovery. Two IIME resulted in hypoxia-induced brain damage and one in death despite of resuscitation.
Approximately 0.1% of all calls registered by the PIC Erfurt from 1997 to 2006 concerned IIME. Thirty-two percent of IIME followed to a known outcome resulted in severe symptoms. These data show that IIME can be harmful.
我们调查了向爱尔福特毒物信息中心（PIC）报告的医源性静脉用药错误（IIME）。
回顾性分析了十年间所有的医源性静脉用药错误，并将其分为错误类型、年龄组、涉及药物以及估计的毒性风险。
1997年至2006年期间，爱尔福特毒物信息中心登记了132例医源性静脉用药错误。这些错误从1997年的7例增加到2006年的31例。受影响的患者中儿童占31.1%，成人占68.9%。最常涉及的药物类别（解剖治疗化学分类）是抗精神病药（9.8%）和全身性使用的抗组胺药（7.5%）。医源性静脉用药错误的主要类型是用药过量（53.1%）和给药途径错误（29.7%）。估计的毒性风险为：无风险14.4%，有毒性风险71.2%，不可预测风险14.4%。82%的情况建议进行医学治疗。132例病程中有104例（78.8%）的结局未知。在已知结局的28例病例中，9例（32%）无症状，19例（68%）有症状，症状轻微（9例）、中度（1例）和重度（6例），但大多完全康复。两例医源性静脉用药错误导致缺氧性脑损伤，一例尽管进行了复苏仍死亡。
1997年至2006年期间，爱尔福特毒物信息中心登记的所有来电中约0.1%与医源性静脉用药错误有关。已知结局的医源性静脉用药错误中有32%导致严重症状。这些数据表明医源性静脉用药错误可能有害。
