Pham Julius Cuong, Story Julie L, Hicks Rodney W, Shore Andrew D, Morlock Laura L, Cheung Dickson S, Kelen Gabor D, Pronovost Peter J
Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
J Emerg Med. 2011 May;40(5):485-92. doi: 10.1016/j.jemermed.2008.02.059. Epub 2008 Sep 26.
Medication errors contribute to significant morbidity, mortality, and costs to the health system. Little is known about the characteristics of Emergency Department (ED) medication errors.
To examine the frequency, types, causes, and consequences of voluntarily reported ED medication errors in the United States.
A cross-sectional study of all ED errors reported to the MEDMARX system between 2000 and 2004. MEDMARX is an anonymous, confidential, de-identified, Internet-accessible medication error-reporting program designed to allow hospitals to report, track, and share error data in a standardized format.
There were 13,932 medication errors from 496 EDs analyzed. The error rate was 78 reports per 100,000 visits. Physicians were responsible for 24% of errors, nurses for 54%. Errors most commonly occurred in the administration phase (36%). The most common type of error was improper dose/quantity (18%). Leading causes were not following procedure/protocol (17%), and poor communication (11%), whereas contributing factors were distractions (7.5%), emergency situations (4.1%), and workload increase (3.4%). Computerized provider order entry caused 2.5% of errors. Harm resulted in 3% of errors. Actions taken as a result of the error included informing the staff member who committed the error (26%), enhancing communication (26%), and providing additional training (12%). Patients or family members were notified about medication errors 2.7% of the time.
ED medication errors may be a result of the acute, crowded, and fast-paced nature of care. Further research is needed to identify interventions to reduce these risks and evaluate the effectiveness of these interventions.
用药错误会导致严重的发病率、死亡率，并给卫生系统带来成本。对于急诊科（ED）用药错误的特征知之甚少。
研究美国急诊科自愿报告的用药错误的发生频率、类型、原因及后果。
对2000年至2004年期间报告给MEDMARX系统的所有急诊科错误进行横断面研究。MEDMARX是一个匿名、保密、去识别化、可通过互联网访问的用药错误报告程序，旨在允许医院以标准化格式报告、跟踪和共享错误数据。
分析了来自496个急诊科的13932例用药错误。错误率为每10万次就诊78例报告。医生导致24%的错误，护士导致54%的错误。错误最常发生在给药阶段（36%）。最常见的错误类型是剂量/数量不当（18%）。主要原因是未遵循程序/方案（17%）和沟通不畅（11%），而促成因素包括注意力分散（7.5%）、紧急情况（4.1%）和工作量增加（3.4%）。计算机化医嘱录入导致2.5%的错误。3%的错误造成了伤害。因错误采取的措施包括告知犯错的工作人员（26%）、加强沟通（26%）和提供额外培训（12%）。2.7%的情况下会通知患者或家属用药错误。
急诊科用药错误可能是由于护理的急性、拥挤和快节奏性质所致。需要进一步研究以确定降低这些风险的干预措施，并评估这些干预措施的有效性。
