Manias Elizabeth, Kinney Sharon, Cranswick Noel, Williams Allison
Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.
J Paediatr Child Health. 2014 Jan;50(1):71-7. doi: 10.1111/jpc.12412. Epub 2013 Oct 6.
This study aims to explore the characteristics of reported medication errors occurring among children in an Australian children's hospital, and to examine the types, causes and contributing factors of medication errors.
A retrospective clinical audit was undertaken of medication errors reported to an online incident facility at an Australian children's hospital over a 4-year period.
A total of 2753 medication errors were reported over the 4-year period, with an overall medication error rate of 0.31% per combined admission and presentation, or 6.58 medication errors per 1000 bed days. The two most common severity outcomes were: the medication error occurred before it reached the child (n = 749, 27.2%); and the medication error reached the child who required monitoring to confirm that it resulted in no harm (n = 1519, 55.2%). Common types of medication errors included overdose (n = 579, 21.0%) and dose omission (n = 341, 12.4%). The most common cause relating to communication involved misreading or not reading medication orders (n = 804, 29.2%). Key contributing factors involved communication relating to children's transfer across different clinical settings (n = 929, 33.7%) and the lack of following policies and procedures (n = 617, 22.4%). More than half of the reports (72.5%) were made by nurses.
Future research should focus on implementing and evaluating strategies aimed at reducing medication errors relating to analgesics, anti-infectives, cardiovascular agents, fluids and electrolytes and anticlotting agents, as they are consistently represented in the types of medication errors that occur. Greater attention needs to be placed on supporting health professionals in managing these medications.
本研究旨在探究澳大利亚一家儿童医院中儿童用药错误报告的特征，并考察用药错误的类型、原因及促成因素。
对一家澳大利亚儿童医院在4年期间向在线事件处理机构报告的用药错误进行回顾性临床审核。
在这4年期间共报告了2753起用药错误，综合入院和就诊的总体用药错误率为每例0.31%，即每1000个床位日有6.58起用药错误。两种最常见的严重程度结果为：用药错误在到达儿童之前发生（n = 749，27.2%）；用药错误到达了儿童，但需要监测以确认未造成伤害（n = 1519，55.2%）。用药错误的常见类型包括用药过量（n = 579，21.0%）和漏服剂量（n = 341，12.4%）。与沟通相关的最常见原因是误读或未阅读用药医嘱（n = 804，29.2%）。关键促成因素包括与儿童在不同临床环境间转运相关的沟通（n = 929，33.7%）以及缺乏遵循政策和程序（n = 617，22.4%）。超过一半的报告（72.5%）由护士提交。
未来研究应聚焦于实施和评估旨在减少与镇痛药、抗感染药、心血管药物、液体和电解质以及抗凝剂相关用药错误的策略，因为这些药物在发生的用药错误类型中一直占比突出。需要更加关注支持卫生专业人员管理这些药物。
