Leite Bartyra, Mistro Sostenes, Carvalho Camile, Mehta Sanjay R, Badaro Roberto
Pharmacy Department, University Hospital Professor Edgard Santos, Bahia, Brazil.
Multidisciplinary Institute of Health, Federal University of Bahia, Brazil.
Int J Qual Health Care. 2016 Jun;28(3):288-93. doi: 10.1093/intqhc/mzw016. Epub 2016 Feb 11.
To evaluate the incidence of medication errors due to dose omissions and the reasons for non-administration of medications.
A cohort study blinded to the nursing staff was conducted for 5 consecutive days to evaluate administration of prescribed medications to selected inpatients.
A major academic teaching hospital in Brazil.
Dispensed doses to patients in medical and surgical wards.
Doses returned to pharmacy were evaluated to identify the rate of dose omission without a justification for omission.
Information was collected from 117 patients in 11 wards and 1119 doses of prescribed medications were monitored. Overall, 238/1119 (21%) dispensed doses were not administered to the patients. Among these 238 doses, 138 (58%) had no justification for not being administered. Failure in the administration of at least 1 dose occurred for 58/117 (49.6%) patients. Surgical wards had significantly more missed doses than that in medical wards (P = 0.048). The daily presence of a pharmacist in the wards was significantly correlated with lower frequency of omission errors (P = 0.019). Nervous system medications were missed more significantly than other medications (P < 0.001). No difference was noted in the omission doses in terms of route of administration.
High incidence of omission errors occurs in our institution. Factors such as the deficit of nursing staff and clinical pharmacists and a weak medication dispensing system, probably contributed to incidence detected. Blinding nursing staff was essential to improve the sensibility of the method for detecting omission errors.
评估因漏服药物导致的用药错误发生率及未给药原因。
对护理人员设盲，连续5天进行队列研究，以评估选定住院患者的医嘱用药给药情况。
巴西一家大型学术教学医院。
内科和外科病房患者的配药剂量。
评估退回药房的剂量，以确定无漏服理由的漏服率。
收集了11个病房117名患者的信息，监测了1119剂医嘱用药。总体而言，238/1119（21%）的配药剂量未给患者使用。在这238剂中，138剂（58%）未给药无正当理由。58/117（49.6%）的患者至少有1剂未给药。外科病房的漏服剂量显著多于内科病房（P = 0.048）。病房每日有药剂师与漏服错误频率较低显著相关（P = 0.019）。神经系统药物漏服比其他药物更显著（P < 0.001）。给药途径方面的漏服剂量无差异。
我们机构漏服错误发生率高。护理人员和临床药师短缺以及药品调配系统薄弱等因素可能导致了所检测到的发生率。对护理人员设盲对于提高漏服错误检测方法的敏感性至关重要。
