Raju T N, Kecskes S, Thornton J P, Perry M, Feldman S
Division of Neonatology, University of Illinois Hospital, College of Medicine, Chicago.
Lancet. 1989 Aug 12;2(8659):374-6. doi: 10.1016/s0140-6736(89)90548-5.
In a 4-year prospective quality assurance study, 315 iatrogenic medication errors were reported among the 2147 neonatal and paediatric intensive-care admissions, an error rate of 1 per 6.8 admissions (14.7%). The frequency of iatrogenic injury of any sort due to a medication error was 66/2147 (3.1%)--1 injury for each 33 intensive-care admissions. 33 (10.5%) errors were potentially serious, 32 (10.2%) caused mild patient injuries, and 1 patient had acute aminophylline poisoning after receiving five intravenous doses of the drug at a dosage ten times higher than prescribed, owing to a calculation error during dilution. A longitudinal monitoring system helps to identify iatrogenic complications due to medication errors and may help in implementing preventive measures.
在一项为期4年的前瞻性质量保证研究中，2147例新生儿和儿科重症监护入院病例中共报告了315例医源性用药错误，错误率为每6.8例入院1例（14.7%）。因用药错误导致的任何类型医源性损伤的发生率为66/2147（3.1%）——每33例重症监护入院中有1例损伤。33例（10.5%）错误可能很严重，32例（10.2%）导致患者轻度受伤，1例患者在接受了五剂静脉注射药物后发生急性氨茶碱中毒，其剂量比规定剂量高十倍，原因是稀释过程中的计算错误。纵向监测系统有助于识别因用药错误导致的医源性并发症，并可能有助于实施预防措施。
