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中国某三甲医院重症监护病房药师干预措施的实施及用药错误评估。

Implementation of pharmacists' interventions and assessment of medication errors in an intensive care unit of a Chinese tertiary hospital.

机构信息

Department of Pharmacy, Zhejiang University, Hangzhou, People's Republic of China.

Intensive Care Unit, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China.

出版信息

Ther Clin Risk Manag. 2014 Oct 9;10:861-6. doi: 10.2147/TCRM.S69585. eCollection 2014.

Abstract

BACKGROUND

Pharmacist interventions and medication errors potentially differ between the People's Republic of China and other countries. This study aimed to report interventions administered by clinical pharmacists and analyze medication errors in an intensive care unit (ICU) in a tertiary hospital in People's Republic of China.

METHOD

A prospective, noncomparative, 6-month observational study was conducted in a general ICU of a tertiary hospital in the People's Republic of China. Clinical pharmacists performed interventions to prevent or resolve medication errors during daily rounds and documented all of these interventions and medication errors. Such interventions and medication errors were categorized and then analyzed.

RESULTS

During the 6-month observation period, a total of 489 pharmacist interventions were reported. Approximately 407 (83.2%) pharmacist interventions were accepted by ICU physicians. The incidence rate of medication errors was 124.7 per 1,000 patient-days. Improper drug frequency or dosing (n=152, 37.3%), drug omission (n=83, 20.4%), and potential or actual occurrence of adverse drug reaction (n=54, 13.3%) were the three most commonly committed medication errors. Approximately 339 (83.4%) medication errors did not pose any risks to the patients. Antimicrobials (n=171, 35.0%) were the most frequent type of medication associated with errors.

CONCLUSION

Medication errors during prescription frequently occurred in an ICU of a tertiary hospital in the People's Republic of China. Pharmacist interventions were also efficient in preventing medication errors.

摘要

背景

药师干预和用药错误在中国和其他国家可能存在差异。本研究旨在报告中国某三级医院重症监护病房(ICU)的临床药师干预措施,并对用药错误进行分析。

方法

采用前瞻性、非对照、6 个月的观察性研究,在中国某三级医院的普通 ICU 进行。临床药师在日常查房时进行干预,以预防或解决用药错误,并记录所有这些干预措施和用药错误。对这些干预措施和用药错误进行分类,然后进行分析。

结果

在 6 个月的观察期间,共报告了 489 次药师干预。大约 407 次(83.2%)药师干预被 ICU 医生接受。用药错误的发生率为 124.7/1000 患者天。最常见的三种用药错误分别是药物频次或剂量不当(n=152,37.3%)、药物遗漏(n=83,20.4%)和潜在或实际发生的药物不良反应(n=54,13.3%)。大约 339 次(83.4%)用药错误未对患者造成任何风险。与错误相关的最常见药物是抗菌药物(n=171,35.0%)。

结论

在中国某三级医院的 ICU 中,处方过程中经常发生用药错误。药师干预在预防用药错误方面也很有效。

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