Hayes Bryan D, Klein-Schwartz Wendy, Gonzales Lawrence F
Maryland Poison Center, School of Pharmacy, University of Maryland, Baltimore, Maryland 21201, USA.
J Am Geriatr Soc. 2009 Apr;57(4):653-8. doi: 10.1111/j.1532-5415.2008.02166.x. Epub 2009 Feb 10.
To evaluate the reasons for unintentional therapeutic errors in older adults, the types of medications most frequently involved, and the medical outcomes related to these adverse drug events.
Retrospective analysis of American Association of Poison Control Center's National Poison Data System (NPDS).
NPDS collects data from all U.S. poison centers. Data from 2002 to 2006 were examined.
Cases involving adults aged 65 and older with a potentially toxic exposure due to unintentional therapeutic errors.
Hazard factor analysis was conducted to identify medications that pose risk in this population.
There were 140,786 older adults with reported therapeutic errors, of which 49,320 cases were followed to a known medical outcome. A major effect or death occurred in 596 cases (1.2% of cases with known medical outcome). The most common reasons for therapeutic errors were inadvertently took or given medication twice, wrong medication taken or given, and other incorrect dose. The reasons associated with the highest rate of major effect or death were drug interaction, health professional or iatrogenic error, and more than one product containing same ingredient. Certain medication classes such as analgesics, anticoagulants, anticonvulsants, asthma therapies, psychotherapeutics, and some cardiovascular agents were associated with high hazard factors.
Poison center data can be used to evaluate therapeutic errors in older adults to identify reasons associated with frequently reported errors, as well as reasons and medications involved with errors that result in serious outcomes. Knowing the reasons why they occur can aid in developing strategies for decreasing unintentional errors in older adults.
评估老年人无意治疗错误的原因、最常涉及的药物类型以及与这些药物不良事件相关的医疗后果。
对美国中毒控制中心协会的国家中毒数据系统（NPDS）进行回顾性分析。
NPDS收集来自美国所有中毒控制中心的数据。对2002年至2006年的数据进行了检查。
涉及65岁及以上成年人因无意治疗错误而有潜在中毒暴露的病例。
进行危险因素分析以确定在该人群中具有风险的药物。
有140,786名老年人报告了治疗错误，其中49,320例追踪到了已知的医疗后果。596例（占已知医疗后果病例的1.2%）发生了重大影响或死亡。治疗错误最常见的原因是无意中重复服药或给药、服用或给予错误药物以及其他剂量错误。与重大影响或死亡率最高相关的原因是药物相互作用、医疗专业人员或医源性错误以及一种以上含有相同成分的产品。某些药物类别，如镇痛药、抗凝药、抗惊厥药、哮喘治疗药、精神治疗药和一些心血管药物，具有高危险因素。
中毒控制中心的数据可用于评估老年人的治疗错误，以确定与频繁报告的错误相关的原因，以及导致严重后果的错误所涉及的原因和药物。了解这些错误发生的原因有助于制定减少老年人无意错误的策略。
