McD Taylor David, Robinson Jeffrey, MacLeod Dawson, MacBean Catherine E, Braitberg George
Emergency andGeneral Medicine Research, Austin Health, Melbourne, Australia.
J Paediatr Child Health. 2009 May;45(5):304-9. doi: 10.1111/j.1440-1754.2008.01462.x. Epub 2009 Mar 23.
This study aimed to determine the epidemiology of therapeutic errors among children in the community setting.
This was a prospective, observational study of 491 consecutive cases reported to the Victorian Poisons Information Centre, between January 2006 and March 2007. A total of 450 (91.7%) parents/carers were followed up by telephone approximately 48 h after the initial call. The main outcome measures were the nature, causes and outcomes of the errors and actions taken or recommendations given to avoid future errors.
The majority of children (334, 68.0%, 95% confidence interval (CI) 63.7, 72.1) were aged <or=3 years. Incorrect and double dosage accounted for 279 (56.8%, 95% CI 52.3, 61.2) and 128 (26.1%, 95% CI 22.3, 30.2) cases, respectively. Almost all errors occurred in the home (98.2%) and involved a single medication (98.8%) and the oral route (98.4%). Close family members were responsible in 408 (83.1%, 95% CI 79.4, 86.2) cases. Analgesics and cough and cold preparations were taken in error in 259 (52.0%) cases. Human (rushing, distraction, carelessness) and communication factors were reported to be causal factors in 337 (38.4%, 95% CI 35.2, 41.8) and 111 (12.7%, 95% CI 10.6, 15.1) cases, respectively. In almost all cases (474, 96.5%, 95% CI 94.4, 97.9), the caller was advised to observe the child at home, and no child experienced significant morbidity. Preventive strategies included attention to administration care and routine, communication, medication storage, administration devices, packaging and labelling issues.
Very young children are at particular risk, especially from single, over-the-counter medication dosing errors, made at home by family members.
本研究旨在确定社区环境中儿童治疗错误的流行病学情况。
这是一项对2006年1月至2007年3月期间向维多利亚州毒物信息中心报告的491例连续病例进行的前瞻性观察研究。在首次致电后约48小时，通过电话对总共450名（91.7%）家长/照顾者进行了随访。主要观察指标为错误的性质、原因和结果，以及为避免未来错误而采取的行动或给出的建议。
大多数儿童（334名，68.0%，95%置信区间（CI）63.7，72.1）年龄≤3岁。用药剂量错误和重复用药分别占279例（56.8%，95%CI 52.3，61.2）和128例（26.1%，95%CI 22.3，30.2）。几乎所有错误都发生在家中（98.2%），涉及单一药物（98.8%）和口服途径（98.4%）。408例（83.1%，95%CI 79.4，86.2）由亲密家庭成员负责。259例（52.0%）误服了镇痛药和止咳感冒药。人为因素（匆忙、分心、粗心）和沟通因素分别被报告为337例（38.4%，95%CI 35.2，41.8）和111例（12.7%，95%CI 10.6，15.1）的因果因素。几乎在所有病例中（474例，96.5%，95%CI 94.4，97.9），建议来电者在家中观察孩子，没有儿童出现严重发病情况。预防策略包括注意给药护理和常规、沟通、药物储存、给药装置、包装和标签问题。
幼儿尤其容易出现风险，特别是在家中由家庭成员造成的单一非处方药给药错误。
