Wahr Joyce A, Shore Andrew D, Harris Lindsay H, Rogers Philippa, Panesar Sukhmeet, Matthew Linda, Pronovost Peter J, Cleary Kevin, Pham Julius C
1University of Michigan School of Medicine, Ann Arbor, MI.
Am J Med Qual. 2014 Jan-Feb;29(1):61-9. doi: 10.1177/1062860613482964. Epub 2013 May 8.
The objective was to compare the characteristics of medication errors reported to 2 national error reporting systems by conducting a cross-sectional analysis of errors reported from adult intensive care units to the UK National Reporting and Learning System and the US MedMarx system. Outcome measures were error types, severity of patient harm, stage of medication process, and involved medications. The authors analyzed 2837 UK error reports and 56 368 US reports. Differences were observed between UK and US errors for wrong dose (44% vs 29%), omitted dose (8.6% vs 27%), and stage of medication process (prescribing: 14% vs 49%; administration: 71% vs 42%). Moderate/severe harm or death was reported in 4.9% of UK versus 3.4% of US errors. Gentamicin was cited in 7.4% of the UK versus 0.7% of the US reports (odds ratio = 9.25). There were differences in the types of errors reported and the medications most often involved. These differences warrant further examination.
目的是通过对从成人重症监护病房报告至英国国家报告与学习系统和美国MedMarx系统的错误进行横断面分析,比较这两个国家错误报告系统所报告的用药错误特征。结果指标为错误类型、患者伤害严重程度、用药过程阶段以及涉及的药物。作者分析了2837份英国错误报告和56368份美国报告。在英国和美国的错误之间观察到以下差异:错误剂量(44%对29%)、漏服剂量(8.6%对27%)以及用药过程阶段(开处方:14%对49%;给药:71%对42%)。英国4.9%的错误报告与美国3.4%的错误报告中提及了中度/重度伤害或死亡。庆大霉素在英国报告中的提及率为7.4%,而在美国报告中的提及率为0.7%(比值比=9.25)。所报告的错误类型和最常涉及的药物存在差异。这些差异值得进一步研究。