Moroccan Pharmacovigilance Centre, Rabat, Marocco.
J Patient Saf. 2009 Mar;5(1):16-22. doi: 10.1097/PTS.0b013e3181990d51.
In recent years, medication error has received considerable attention because it causes substantial mortality, morbidity, and additional health care costs. Collecting information in this field depends on the willingness of health professionals to report their errors. Another important point is to identify patients at high risk for an adverse drug event (ADE) to oversee the quality of the entire drug distribution chain, including prescription, drug choice, dispensing, and preparation to the administration of drugs.
To assess the prevalence rate of ADEs. To ascertain those related to medication errors to develop prevention strategies.
Prospective cohort study.
Multicenter study, 7 intensive care unit in academic and military hospital of Rabat.
Three months.
Adult and pediatric patients in medical/surgical intensive care units. COLLECTION DATA: One coordinator for each participating ward collaborates with a pharmacist investigator from Moroccan pharmacovigilance center in the detection of ADEs.
Of the 696 patients studied, the investigators identified 108 incidents (15.5 %) (95% confidence interval, 14.1-16.9). The reviewers concluded that 56 (70%) of 80 ADEs were nonpreventable, which, by definition, are considered as ADRs. Among the 52 medication errors, 28 (53.8%) led to potential ADEs and 24 (46.2%) led to actual preventable ADEs. There were 7.7 medication errors for 1000 patient-days. We noted that the preventable ADEs occurred in the prescribing (71.1%), administration (21.2%), transcription (5.7%), and dispensing stages. Errors of wrong or improper drug use accounted for the majority of potential and actual preventable ADEs (23%), followed by improper dose (21.1%), wrong duration of treatment (19.2%),wrong rate of administration(13.5), errors due to drug omission (9.6%), wrong administration technique (5.8%), wrong dosage form (3.8%), and wrong administration timing (1.9%).
This study argues the need for pharmacovigilance to extend its scope to medication errors to improve the safety of drugs. Our results underlined that medication errors are likely to be more serious than ADRs. Our approach based on the collaboration between the pharmacovigilance center and clinicians can be a powerful tool for incorporating error reporting into the culture of medicine.
近年来，由于用药错误会导致大量的死亡、发病和额外的医疗费用，因此引起了广泛关注。在该领域收集信息取决于卫生专业人员报告错误的意愿。另一个重要的问题是识别出有发生药物不良事件（ADE）风险的患者，以监督整个药物分发链的质量，包括处方、药物选择、配药、准备到药物给药。
评估 ADE 的发生率。确定与用药错误相关的事件，以制定预防策略。
前瞻性队列研究。
在拉巴特的学术和军事医院的 7 个重症监护病房进行的多中心研究。
三个月。
内科/外科重症监护病房的成人和儿科患者。
每个参与病房的一名协调员与来自摩洛哥药物警戒中心的药剂师调查员合作，以发现 ADE。
在 696 名研究患者中，研究人员发现了 108 起事件（15.5%）（95%置信区间，14.1-16.9）。审查员得出结论，80 起 ADE 中有 56 起（70%）是非预防的，根据定义，这些 ADE 被认为是不良反应。在 52 起用药错误中，有 28 起（53.8%）导致潜在的 ADE，24 起（46.2%）导致实际可预防的 ADE。每 1000 患者天发生 7.7 次用药错误。我们注意到，可预防的 ADE 发生在开处方（71.1%）、给药（21.2%）、转录（5.7%）和配药阶段。用药错误，如用药错误或不当，占潜在和实际可预防 ADE 的大多数（23%），其次是剂量不当（21.1%）、治疗时间不当（19.2%）、给药速度不当（13.5%）、药物遗漏引起的错误（9.6%）、给药技术不当（5.8%）、剂型错误（3.8%）和给药时间不当（1.9%）。
本研究认为药物警戒需要扩大范围以涵盖用药错误，以提高药物安全性。我们的结果强调，用药错误可能比不良反应更严重。我们基于药物警戒中心和临床医生合作的方法，可以成为将错误报告纳入医学文化的有力工具。
