Chua S S, Tea M H, Rahman M H A
Department of Pharmacy, Faculty of Medicine, University of Malaysia, Kuala Lumpur, Malaysia.
J Clin Pharm Ther. 2009 Apr;34(2):215-23. doi: 10.1111/j.1365-2710.2008.00997.x.
Drug administration errors were the second most frequent type of medication errors, after prescribing errors but the latter were often intercepted hence, administration errors were more probably to reach the patients. Therefore, this study was conducted to determine the frequency and types of drug administration errors in a Malaysian hospital ward.
This is a prospective study that involved direct, undisguised observations of drug administrations in a hospital ward. A researcher was stationed in the ward under study for 15 days to observe all drug administrations which were recorded in a data collection form and then compared with the drugs prescribed for the patient.
A total of 1118 opportunities for errors were observed and 127 administrations had errors. This gave an error rate of 11.4 % [95% confidence interval (CI) 9.5-13.3]. If incorrect time errors were excluded, the error rate reduced to 8.7% (95% CI 7.1-10.4). The most common types of drug administration errors were incorrect time (25.2%), followed by incorrect technique of administration (16.3%) and unauthorized drug errors (14.1%). In terms of clinical significance, 10.4% of the administration errors were considered as potentially life-threatening. Intravenous routes were more likely to be associated with an administration error than oral routes (21.3% vs. 7.9%, P < 0.001).
The study indicates that the frequency of drug administration errors in developing countries such as Malaysia is similar to that in the developed countries. Incorrect time errors were also the most common type of drug administration errors. A non-punitive system of reporting medication errors should be established to encourage more information to be documented so that risk management protocol could be developed and implemented.
给药错误是仅次于处方错误的第二常见用药错误类型，但后者往往能被拦截，因此给药错误更有可能影响到患者。因此，本研究旨在确定马来西亚一家医院病房给药错误的发生率及类型。
这是一项前瞻性研究，对医院病房的给药情况进行直接、无掩饰的观察。一名研究人员在研究病房驻点15天，观察所有给药情况，并记录在数据收集表中，然后与为患者开具的药物进行比较。
共观察到1118次可能出现错误的给药机会，其中127次给药存在错误。错误率为11.4%[95%置信区间（CI）9.5 - 13.3]。若排除给药时间错误，错误率降至8.7%（95%CI 7.1 - 10.4）。最常见的给药错误类型是给药时间错误（25.2%），其次是给药技术错误（16.3%）和未经授权用药错误（14.1%）。就临床意义而言，10.4%的给药错误被认为可能危及生命。静脉给药途径比口服给药途径更易出现给药错误（21.3%对7.9%，P < 0.001）。
该研究表明，在马来西亚等发展中国家，给药错误的发生率与发达国家相似。给药时间错误也是最常见的给药错误类型。应建立一个非惩罚性的用药错误报告系统，以鼓励记录更多信息，从而制定和实施风险管理方案。
