Department of Pharmacy, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
J Am Med Inform Assoc. 2012 Jan-Feb;19(1):72-8. doi: 10.1136/amiajnl-2011-000332. Epub 2011 Sep 2.
To identify the frequency of medication administration errors and their potential risk factors in units using a computerized prescription order entry program and profiled automated dispensing cabinets.
Prospective observational study conducted within two clinical units of the Gastroenterology Department in a 1537-bed tertiary teaching hospital in Madrid (Spain).
Medication errors were measured using the disguised observation technique. Types of medication errors and their potential severity were described. The correlation between potential risk factors and medication errors was studied to identify potential causes.
In total, 2314 medication administrations to 73 patients were observed: 509 errors were recorded (22.0%)-68 (13.4%) in preparation and 441 (86.6%) in administration. The most frequent errors were use of wrong administration techniques (especially concerning food intake (13.9%)), wrong reconstitution/dilution (1.7%), omission (1.4%), and wrong infusion speed (1.2%). Errors were classified as no damage (95.7%), no damage but monitoring required (2.3%), and temporary damage (0.4%). Potential clinical severity could not be assessed in 1.6% of cases. The potential risk factors morning shift, evening shift, Anatomical Therapeutic Chemical medication class antacids, prokinetics, antibiotics and immunosuppressants, oral administration, and intravenous administration were associated with a higher risk of administration errors. No association was found with variables related to understaffing or nurse's experience.
Medication administration errors persist in units with automated prescription and dispensing. We identified a need to improve nurses' working procedures and to implement a Clinical Decision Support tool that generates recommendations about scheduling according to dietary restrictions, preparation of medication before parenteral administration, and adequate infusion rates.
在使用计算机化医嘱录入程序和配置自动化发药柜的单元中，确定给药错误的频率及其潜在危险因素。
在马德里（西班牙）一家拥有 1537 张床位的三级教学医院的胃肠科两个临床单元内进行的前瞻性观察性研究。
使用伪装观察技术测量给药错误。描述了给药错误的类型及其潜在严重程度。研究了潜在危险因素与给药错误之间的相关性，以确定潜在的原因。
共观察了 73 名患者的 2314 次给药：记录了 509 次错误（22.0%）-准备过程中有 68 次（13.4%），给药过程中有 441 次（86.6%）。最常见的错误是使用错误的给药技术（尤其是关于进食（13.9%））、错误的配制/稀释（1.7%）、遗漏（1.4%）和错误的输注速度（1.2%）。错误被归类为无损害（95.7%）、无损害但需要监测（2.3%）和暂时损害（0.4%）。在 1.6%的情况下无法评估潜在临床严重程度。潜在危险因素包括：早班、晚班、解剖治疗化学药物类别抗酸药、促动力药、抗生素和免疫抑制剂、口服给药和静脉内给药，与给药错误的风险增加相关。与人员配备不足或护士经验相关的变量没有关联。
自动化医嘱和发药单元中仍存在给药错误。我们发现需要改进护士的工作流程，并实施临床决策支持工具，根据饮食限制、肠外给药前的药物准备以及适当的输注速度生成有关安排的建议。
