Dhawan Ira, Tewari Anurag, Sehgal Sankalp, Sinha Ashish Chandra
Department of Anesthesia, PGIMER, Chandigarh, India.
Cincinnati Children's Hospital and Medical Center, Cincinnati, OH, USA.
Braz J Anesthesiol. 2017 Mar-Apr;67(2):184-192. doi: 10.1016/j.bjane.2015.09.006. Epub 2016 May 16.
Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.
用药错误是导致患者发病和死亡的常见原因。它也给医疗机构增加了经济负担。尽管其影响从无伤害到包括死亡在内的严重不良反应各不相同,但由于用药错误是可预防的,因此需要优先予以关注。在当今人们意识增强且医疗索赔不断增加的世界里,遏制这一问题是重中之重。在现有方案和系统没有改变的情况下,仅靠个人努力减少用药错误可能不会成功。发生的用药错误往往无法挽回。“治疗”用药错误的最佳方法是预防它们。错误用药(由于注射器交换)、用药过量(由于对剂量的误解或先入之见、泵使用不当和稀释错误)、给药途径错误、用药不足和漏用是围手术期发生用药错误的常见原因。漏用药物和计算错误在重症监护病房很常见。用药错误可在围手术期的准备、给药或记录保存过程中发生。用药错误的发生可归咎于众多人为和系统错误。当务之急是停止指责游戏,承认错误并营造一种安全且“公正”的文化氛围,以预防用药错误。新设计的系统如VEINROM,一种液体输送系统,是预防麻醉中最常用药物导致用药错误的新方法。类似的进展,再加上警惕的医生、安全的工作场所文化和组织支持,共同有助于预防这些错误。