Jiménez Muñioz Ana Belén, Muiño Miguez Antonio, Rodriguez Pérez Maria Paz, Escribano María Dolores Vigil, Durán Garcia María Esther, Sanjurjo Saez María
Hospital General, Universitario Gregorio Marañón, Madrid, Spain.
Int J Health Care Qual Assur. 2010;23(3):328-38. doi: 10.1108/09526861011029389.
Healthcare risk epidemiology identifies medication error as the commonest cause of adverse effects on patients. Medication error can occur at any phase of the complex medication process so prevalence rates need to be estimated at each drug treatment phase: prescription, transcription and administration along with their clinical repercussions. This paper aims to investigate this issue.
DESIGN/METHODOLOGY/APPROACH: Medication errors were recorded on an ad hoc sheet and staff were observed handling medications. Recorded errors were later classified and their clinical repercussions determined by experts.
In total 757 inpatients and 5466 drug prescriptions were studied. The prescription error rate was 4.79 percent (95 percent CI 4.21-5.36). The most frequent error in this phase was failing to observe international prescribing standards. The highest error rate was found in transcription (14.61 percent, 95 percent CI 13.67-15.54). Almost 1900 dose administrations were observed. There was a 9.32 percent error rate (95 percent CI 7.98-10.67). The commonest error in this phase was omission. Most were transcription errors, which were detected before harm wasdone.
RESEARCH LIMITATIONS/IMPLICATIONS: The dispensation phase is absent.
Errors can be reduced if they are understood. Education and training based on the study's findings can reduce medication errors.
ORIGINALITY/VALUE: The paper highlights ways to reduce errors in the medication process.
医疗风险流行病学将用药错误确定为对患者产生不良反应的最常见原因。用药错误可能发生在复杂用药过程的任何阶段，因此需要在每个药物治疗阶段估计其发生率：处方、转录和给药阶段及其临床影响。本文旨在研究这一问题。
设计/方法/途径：在一张特制表格上记录用药错误，并观察工作人员处理药物的情况。记录的错误随后进行分类，其临床影响由专家确定。
共研究了757名住院患者和5466张药物处方。处方错误率为4.79%（95%置信区间4.21 - 5.36）。该阶段最常见的错误是未遵守国际处方标准。转录阶段的错误率最高（14.61%，95%置信区间13.67 - 15.54）。观察了近1900次给药过程。错误率为9.32%（95%置信区间7.98 - 10.67）。此阶段最常见的错误是遗漏。大多数是转录错误，在造成伤害之前被发现。
研究局限性/影响：未包括配药阶段。
如果能理解错误，就可以减少错误。基于研究结果进行教育和培训可以减少用药错误。
原创性/价值：本文强调了减少用药过程中错误的方法。
