未预防或已预防的调配事件：调配差错研究应采用哪种结果？

Unprevented or prevented dispensing incidents: which outcome to use in dispensing error research?

作者信息

James K Lynette, Barlow Dave, Burfield Robin, Hiom Sarah, Roberts Dave, Whittlesea Cate

机构信息

Pharmaceutical Science Division, Clinical Practice & Medication Use Group, King's College London, London, UK.

出版信息

Int J Pharm Pract. 2011 Feb;19(1):36-50. doi: 10.1111/j.2042-7174.2010.00071.x.

DOI:10.1111/j.2042-7174.2010.00071.x

PMID:21235658

Abstract

OBJECTIVES

To compare the rate, error type, causes and clinical significance of unprevented and prevented dispensing incidents reported by Welsh National Health Service (NHS) hospital pharmacies.

METHODS

Details of all unprevented and prevented dispensing incidents occurring over 3 months (September-December 2005) at five district general hospitals across Wales were reported and analysed using a validated method. Rates of unprevented and prevented dispensing incidents were compared using Mann-Whitney U test. Reported error types, contributory factors and clinical significance of unprevented and prevented incidents were compared using Fisher's exact test.

KEY FINDINGS

Thirty-five unprevented and 291 prevented dispensing incidents were reported amongst 221,670 items. The rate of unprevented (16/100,000 items) and prevented dispensing incidents (131/100,000 items; P = 0.04) was significantly different. There was a significant difference in the proportions of prevented and unprevented dispensing incidents involving the wrong directions/warnings on the label (prevented, n = 100, 29%; unprevented, n = 4, 10%; P = 0.02) and the wrong drug details on the label (prevented, n = 15, 4%; unprevented, n = 6, 14%; P = 0.01). There was a significant difference in the proportions of prevented and unprevented dispensing incidents involving supply of the wrong strength (prevented, n = 46, 14%; unprevented, n = 2, 5%; P = 0.02) and issue of expired medicines (prevented, n = 3, 1%; unprevented, n = 5, 12%; P = 0.002).

CONCLUSION

The use of prevented dispensing incidents as a surrogate marker for unprevented incidents is questionable. There were significant differences between unprevented and prevented dispensing incidents in terms of rate and error types. This is consistent with the medication error iceberg. Care must be exercised when extrapolating prevented dispensing incident data on error types to unprevented dispensing incidents.

摘要

目的

比较威尔士国民医疗服务体系（NHS）医院药房报告的未预防和已预防调配事件的发生率、错误类型、原因及临床意义。

方法

采用一种经过验证的方法，报告并分析了威尔士五家地区综合医院在3个月（2005年9月至12月）内发生的所有未预防和已预防调配事件的详细情况。使用曼-惠特尼U检验比较未预防和已预防调配事件的发生率。使用费舍尔精确检验比较已报告的未预防和已预防事件的错误类型、促成因素及临床意义。

主要发现

在221,670项药品中，报告了35起未预防调配事件和291起已预防调配事件。未预防调配事件的发生率（16/100,000项）与已预防调配事件的发生率（131/100,000项；P = 0.04）存在显著差异。在涉及标签上错误的用法说明/警示（已预防，n = 100，29%；未预防，n = 4，10%；P = 0.02）以及标签上错误的药品详情（已预防，n = 仅15，4%；未预防，n = 6，14%；P = 0.01）的未预防和已预防调配事件比例上存在显著差异。在涉及供应错误规格药品（已预防，n = 46，14%；未预防，n = 2，5%；P = 0.02）和发放过期药品（已预防，n = 3，1%；未预防，n = 5，12%；P = 0.002）的未预防和已预防调配事件比例上也存在显著差异。