King's College London, King's Health Partners, Pharmaceutical Science Clinical Academic Group, Institute of Pharmaceutical Science, Franklin-Wilkins Building, 150 Stamford St, London, SE1 9NH, UK,
Int J Clin Pharm. 2013 Oct;35(5):772-9. doi: 10.1007/s11096-013-9805-9. Epub 2013 Jun 21.
Medication incidents (MIs) account for 11.3 % of all reported patient-safety incidents in England and Wales. Approximately one-third of inpatients are prescribed an antibiotic at some point during their hospital stay. The WHO has identified incident reporting as one solution to reduce the recurrence of adverse incidents.
The aim of this study was to determine the number and nature of reported antibiotic-associated MIs occurring in inpatients and to use defined daily doses (DDDs) to calculate the incident rate for the antibiotics most commonly associated with MIs at each hospital.
Two UK acute NHS teaching hospitals.
Retrospective quantitative analysis was performed on antibiotic-associated MIs reported to the risk management system over a 2-year period. Quality-assurance measures were undertaken before analysis. The study was approved by the clinical audit departments at both hospitals. Drug consumption data from each hospital were used to calculate the DDD for each antibiotic.
The number of antibiotic-related MIs reported and the incident rate for the 10 antibiotics most commonly associated with MIs at each hospital.
Healthcare staff submitted 6,756 reports, of which 885 (13.1 %) included antibiotics. This resulted in a total of 959 MIs. Most MIs occurred during prescribing (42.4 %, n = 407) and administration (40.0 %, n = 384) stages. Most common types of MIs were omission/delay (26.3 %, n = 252), and dose/frequency (17.9 %, n = 172). Penicillins (34.5 %, n = 331) and aminoglycosides (16.6 %, n = 159) were the most frequently reported groups with co-amoxiclav (16.8 %, n = 161) and gentamicin (14.1 %, n = 135) the most frequently reported drugs. Using DDDs to assess the incident rate showed that cefotaxime (105.4/10,000 DDDs), gentamicin (25.7/10,000 DDDs) and vancomycin (23.7/10,000 DDDs) had the highest rates.
This study highlights that detailed analysis of data from reports is essential in understanding MIs and developing strategies to prevent their recurrence. Using DDDs in the analysis of MIs allowed determination of an incident rate providing more useful information than the absolute numbers alone. It also highlighted the disproportionate risk associated with less commonly prescribed antibiotics not identified using MI reporting rates alone.
在英格兰和威尔士，药物事件（MIs）占所有报告的患者安全事件的 11.3%。大约三分之一的住院患者在住院期间的某个时候被开了抗生素。世界卫生组织已将事件报告确定为减少不良事件复发的解决方案之一。
本研究旨在确定报告的与抗生素相关的 MIs 在住院患者中发生的数量和性质，并使用定义日剂量（DDD）来计算每家医院最常与 MIs 相关的抗生素的发生率。
英国两家急性 NHS 教学医院。
对风险管理系统报告的两年期间与抗生素相关的 MIs 进行回顾性定量分析。在分析之前进行了质量保证措施。该研究得到了两家医院临床审计部门的批准。从每家医院使用药物使用数据计算每种抗生素的 DDD。
报告的抗生素相关 MIs 的数量以及每家医院最常与 MIs 相关的 10 种抗生素的发生率。
医护人员提交了 6756 份报告，其中 885 份（13.1%）包含抗生素。这导致了总共 959 例 MIs。大多数 MIs 发生在开处方（42.4%，n=407）和给药（40.0%，n=384）阶段。最常见的 MIs 类型是遗漏/延迟（26.3%，n=252）和剂量/频率（17.9%，n=172）。青霉素（34.5%，n=331）和氨基糖苷类（16.6%，n=159）是最常报告的组，其中复方阿莫西林（16.8%，n=161）和庆大霉素（14.1%，n=135）是最常报告的药物。使用 DDD 评估发生率表明，头孢噻肟（105.4/10000 DDD）、庆大霉素（25.7/10000 DDD）和万古霉素（23.7/10000 DDD）的发生率最高。
本研究表明，详细分析报告中的数据对于了解 MIs 并制定预防其复发的策略至关重要。在分析 MIs 时使用 DDD 可以确定发生率，提供比仅使用绝对数字更有用的信息。它还突出了单独使用 MI 报告率未识别的使用频率较低的抗生素相关的不成比例的风险。
