Maaskant Jolanda, Bosman Diederik, van Rijn-Bikker Petra, van Aalderen Wim, Vermeulen Hester
Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands.
Department of Clinical Pharmacy, Academic Medical Center, Amsterdam, The Netherlands.
Eur J Pediatr Surg. 2014 Oct;24(5):381-8. doi: 10.1055/s-0033-1352526. Epub 2013 Aug 21.
Many hospitalized patients are affected by medication errors (MEs) that may cause discomfort, harm, and even death. Especially, children are considered to be at high risk of experiencing harm due to MEs. More insight into the prevalence, type, and severity of harm caused by MEs could help reduce the frequency of these harmful events. The primary objectives of our study were to establish the prevalence of different types of MEs and the severity of harm caused by MEs in hospitalized children from birth to 18 years of age. In addition, we investigated correlations between harmful MEs and characteristics of the collected data from 426 hospitalized children admitted, and the medication process.
In this cross-sectional study, we identified MEs by reviewing clinical records, making direct observations, monitoring pharmacy logs, and reviewing voluntary incident reports. Subsequently, the MEs were classified according to type of error, medication group and stage of the medication process. Pediatricians rated the severity of the observed harm.
We collected data from 426 hospitalized children admitted during August to October 2011. A total of 322 MEs were identified, of which 39 caused patient harm. Harmful events were mainly because of wrong time (41%). Pediatricians rated the observed harm as minor in 77% of the incidents and significant in 23%. None of the harmful MEs resulted in permanent harm or was considered life-threatening or fatal. Patients admitted for a surgical procedure were at higher risk for a harmful event compared with patients admitted for nonsurgical reasons (adjusted odds ratio 2.79, 95% confidence interval; 1.35-5.80). Nonopioid analgesics and antiemetic drugs accounted for 67% of the harmful MEs. Harmful MEs occurred most frequently during medication prescription (28%) and administration (62%).
Surgical pediatric patients seem to be at high risk for harmful MEs. Although the harm was considered minor in most cases, it still caused discomfort for the patients, and the high prevalence is a source of concern. Interventions to prevent the MEs should focus on the prescription and administration of nonopioid analgesics and antiemetic drugs.
许多住院患者会受到用药错误（MEs）的影响，这些错误可能导致不适、伤害甚至死亡。尤其是儿童，被认为因用药错误而遭受伤害的风险很高。更深入了解用药错误造成的伤害的发生率、类型和严重程度，有助于减少这些有害事件的发生频率。我们研究的主要目的是确定18岁以下住院儿童中不同类型用药错误的发生率以及用药错误造成的伤害的严重程度。此外，我们调查了426名住院儿童收集的数据特征、用药过程与有害用药错误之间的相关性。
在这项横断面研究中，我们通过审查临床记录、直接观察、监测药房日志和审查自愿事件报告来识别用药错误。随后，根据错误类型、药物类别和用药过程阶段对用药错误进行分类。儿科医生对观察到的伤害的严重程度进行评级。
我们收集了2011年8月至10月期间住院的426名儿童的数据。共识别出322起用药错误，其中39起导致患者伤害。有害事件主要是由于用药时间错误（41%）。儿科医生将77%的事件中观察到的伤害评为轻微，23%评为严重。没有有害用药错误导致永久性伤害，也没有被认为危及生命或致命。与因非手术原因住院的患者相比，接受手术的住院患者发生有害事件的风险更高（调整后的优势比为2.79，95%置信区间为1.35 - 5.80）。非阿片类镇痛药和止吐药占有害用药错误的67%。有害用药错误最常发生在用药处方阶段（28%）和给药阶段（62%）。
儿科手术患者似乎发生有害用药错误的风险很高。虽然在大多数情况下伤害被认为是轻微的，但仍给患者带来不适，而且高发生率令人担忧。预防用药错误的干预措施应侧重于非阿片类镇痛药和止吐药的处方和给药。
