Department of Clinical Pharmacy, Isala Clinics, Zwolle, The Netherlands.
Arch Dis Child Fetal Neonatal Ed. 2012 Nov;97(6):F449-55. doi: 10.1136/fetalneonatal-2011-300989. Epub 2012 Apr 5.
To examine the effect of a multifaceted educational intervention on the incidence of medication preparation and administration errors in a neonatal intensive care unit (NICU).
Prospective study with a preintervention and postintervention measurement using direct observation.
NICU in a tertiary hospital in the Netherlands.
A multifaceted educational intervention including teaching and self-study.
The incidence of medication preparation and administration errors. Clinical importance was assessed by three experts.
The incidence of errors decreased from 49% (43-54%) (151 medications with one or more errors of 311 observations) to 31% (87 of 284) (25-36%). Preintervention, 0.3% (0-2%) medications contained severe errors, 26% (21-31%) moderate and 23% (18-28%) minor errors; postintervention, none 0% (0-2%) was severe, 23% (18-28%) moderate and 8% (5-12%) minor. A generalised estimating equations analysis provided an OR of 0.49 (0.29-0.84) for period (p=0.032), (route of administration (p=0.001), observer within period (p=0.036)).
The multifaceted educational intervention seemed to have contributed to a significant reduction of the preparation and administration error rate, but other measures are needed to improve medication safety further.
研究多方位教育干预对新生儿重症监护病房（NICU）中药物准备和给药错误发生率的影响。
前瞻性研究，采用预干预和后干预的直接观察测量。
荷兰一家三级医院的 NICU。
包括教学和自学在内的多方位教育干预。
药物准备和给药错误的发生率。三位专家评估了临床重要性。
错误发生率从 49%（43-54%）（311 次观察中有 151 种药物出现 1 次或多次错误）降至 31%（284 种药物中有 87 种）（25-36%）。干预前，0.3%（0-2%）的药物存在严重错误，26%（21-31%）为中度错误，23%（18-28%）为轻度错误；干预后，无 0%（0-2%）的药物严重，23%（18-28%）为中度，8%（5-12%）为轻度。广义估计方程分析提供了一个比值比（OR）为 0.49（0.29-0.84），表明时期（p=0.032），（给药途径（p=0.001），观察者在时期内（p=0.036））之间存在差异。
多方位教育干预似乎有助于显著降低准备和给药错误率，但需要采取其他措施进一步提高药物安全性。
