Merino P, Martín M C, Alonso A, Gutiérrez I, Alvarez J, Becerril F
Servicio de Medicina Intensiva, Hospital Can Misses, Ibiza, España.
Med Intensiva. 2013 Aug-Sep;37(6):391-9. doi: 10.1016/j.medin.2012.11.002. Epub 2013 Jan 9.
To estimate the incidence of medication errors in Spanish intensive care units.
Post hoc study of the SYREC trial. A longitudinal observational study carried out during 24 hours in patients admitted to the ICU.
Spanish intensive care units.
Patients admitted to the intensive care unit participating in the SYREC during the period of study.
Risk, individual risk, and rate of medication errors.
The final study sample consisted of 1017 patients from 79 intensive care units; 591 (58%) were affected by one or more incidents. Of these, 253 (43%) had at least one medication-related incident. The total number of incidents reported was 1424, of which 350 (25%) were medication errors. The risk of suffering at least one incident was 22% (IQR: 8-50%) while the individual risk was 21% (IQR: 8-42%). The medication error rate was 1.13 medication errors per 100 patient-days of stay. Most incidents occurred in the prescription (34%) and administration (28%) phases, 16% resulted in patient harm, and 82% were considered "totally avoidable".
Medication errors are among the most frequent types of incidents in critically ill patients, and are more common in the prescription and administration stages. Although most such incidents have no clinical consequences, a significant percentage prove harmful for the patient, and a large proportion are avoidable.
评估西班牙重症监护病房用药错误的发生率。
SYREC试验的事后分析。对入住重症监护病房的患者进行为期24小时的纵向观察性研究。
西班牙重症监护病房。
在研究期间入住参与SYREC研究的重症监护病房的患者。
风险、个体风险和用药错误率。
最终研究样本包括来自79个重症监护病房的1017名患者;591名(58%)患者受到一次或多次不良事件影响。其中,253名(43%)患者至少发生一次与用药相关的不良事件。报告的不良事件总数为1424起,其中350起(25%)为用药错误。发生至少一次不良事件的风险为22%(四分位间距:8%-50%),而个体风险为21%(四分位间距:8%-42%)。用药错误率为每100患者住院日1.13次用药错误。大多数不良事件发生在处方(34%)和给药(28%)阶段,16%导致患者伤害,82%被认为“完全可以避免”。
用药错误是重症患者中最常见的不良事件类型之一,在处方和给药阶段更为常见。虽然大多数此类不良事件没有临床后果,但相当比例的事件对患者有害,且很大一部分是可以避免的。