围手术期用药错误与药物不良事件的评估
Evaluation of Perioperative Medication Errors and Adverse Drug Events.
作者信息
Nanji Karen C, Patel Amit, Shaikh Sofia, Seger Diane L, Bates David W
机构信息
From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts (K.C.N., A.P., S.S.); Departments of Anesthesia (K.C.N.) and Medicine (D.W.B.), Harvard Medical School, Boston, Massachusetts; Partners Healthcare Systems, Inc., Wellesley, Massachusetts (K.C.N., D.L.S., D.W.B.); and Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (D.W.B.).
出版信息
Anesthesiology. 2016 Jan;124(1):25-34. doi: 10.1097/ALN.0000000000000904.
BACKGROUND
The purpose of this study is to assess the rates of perioperative medication errors (MEs) and adverse drug events (ADEs) as percentages of medication administrations, to evaluate their root causes, and to formulate targeted solutions to prevent them.
METHODS
In this prospective observational study, anesthesia-trained study staff (anesthesiologists/nurse anesthetists) observed randomly selected operations at a 1,046-bed tertiary care academic medical center to identify MEs and ADEs over 8 months. Retrospective chart abstraction was performed to flag events that were missed by observation. All events subsequently underwent review by two independent reviewers. Primary outcomes were the incidence of MEs and ADEs.
RESULTS
A total of 277 operations were observed with 3,671 medication administrations of which 193 (5.3%; 95% CI, 4.5 to 6.0) involved a ME and/or ADE. Of these, 153 (79.3%) were preventable and 40 (20.7%) were nonpreventable. The events included 153 (79.3%) errors and 91 (47.2%) ADEs. Although 32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed ADE and an additional 70 (45.8%) had the potential for patient harm. Of the 153 errors, 99 (64.7%) were serious, 51 (33.3%) were significant, and 3 (2.0%) were life-threatening.
CONCLUSIONS
One in 20 perioperative medication administrations included an ME and/or ADE. More than one third of the MEs led to observed ADEs, and the remaining two thirds had the potential for harm. These rates are markedly higher than those reported by retrospective surveys. Specific solutions exist that have the potential to decrease the incidence of perioperative MEs.
背景
本研究的目的是评估围手术期用药错误（MEs）和药物不良事件（ADEs）占给药次数的百分比，评估其根本原因，并制定针对性的解决方案以预防这些情况。
方法
在这项前瞻性观察研究中，经过麻醉培训的研究人员（麻醉医生/麻醉护士）在一家拥有1046张床位的三级医疗学术医学中心随机观察选定的手术，以确定8个月内的用药错误和药物不良事件。进行回顾性病历摘要以标记观察中遗漏的事件。所有事件随后由两名独立的审查员进行审查。主要结局是用药错误和药物不良事件的发生率。
结果
共观察了277例手术，进行了3671次给药，其中193次（5.3%；95%置信区间，4.5至6.0）涉及用药错误和/或药物不良事件。其中，153次（79.3%）是可预防的，40次（20.7%）是不可预防的。这些事件包括153次（79.3%）错误和91次（47.2%）药物不良事件。虽然32次（20.9%）错误造成伤害的可能性很小，但51次（33.3%）导致了观察到的药物不良事件，另外70次（45.8%）有可能对患者造成伤害。在153次错误中，99次（64.7%）是严重的，51次（33.3%）是显著的，3次（2.0%）是危及生命的。
结论
每20次围手术期给药中就有1次涉及用药错误和/或药物不良事件。超过三分之一的用药错误导致了观察到的药物不良事件，其余三分之二有可能造成伤害。这些发生率明显高于回顾性调查所报告的发生率。存在一些有可能降低围手术期用药错误发生率的具体解决方案。
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