Ewig Celeste L Y, Cheung Hon Ming, Kam Kwok Ho, Wong Hiu Lam, Knoderer Chad A
School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.
Paediatr Drugs. 2017 Aug;19(4):347-355. doi: 10.1007/s40272-017-0222-8.
Critically ill pediatric patients are considered at high risk for medication errors. Although much research focuses on the actual errors, equally important are medication errors that, although intercepted, carried the potential for an adverse drug event. The aim of this study was to determine the occurrence of prescribing errors and potential adverse drug events (pADEs) in a local pediatric intensive and critical care unit (PICU) in Hong Kong. Our secondary objective was to determine the type of error, nature of medication involved and the time of error occurrence.
We conducted a prospective observational chart review among patients in a pediatric intensive and high dependency unit between January 16, 2015 and April 20, 2015. Medical charts for each patient were reviewed for the occurrence of a prescribing error or pADE. Each pADE was assessed for the type of error, the classification of agent involved, clinical severity of the error, and the time the error occurred.
Forty-one patients with a mean age of 3.2 years were included in our study. Of these patients, 19 (46.3%) experienced at least one pADE. We identified 131 pADEs, 129 of which were prescribing errors conferring a rate of 6.8 errors per affected patient or 3.1 errors per patient admitted to the PICU. The most common error found in the study was incorrect dose calculation (48.1%), with intravenous fluids (41.7%), cardiovascular agents (15.0%), and anti-infectives (12.5%) the most common agents involved with an error. The majority of the pADEs in our study were either clinically serious (33.1%) or significant (44.9%) in nature. Nearly one in every four errors required monitoring and/or intervention to prevent harm, and almost all (96.9%) of the prescribing errors were intercepted before reaching the patient.
This study highlights incorrect dose calculation as the most common prescribing error in a pediatric critical care setting. Intravenous fluids, cardiovascular agents, and anti-infectives were the classes of medication most commonly involved with a pADE. Due to the high-risk nature of medications used and the critical condition of these patients, more than three-quarters of pADEs were considered to be clinically serious or significant in causing patient harm.
危重症儿科患者被认为是用药错误的高危人群。尽管许多研究聚焦于实际发生的错误，但同样重要的是那些虽被拦截但仍有引发药物不良事件可能性的用药错误。本研究的目的是确定香港一家本地儿科重症监护病房（PICU）中处方错误及潜在药物不良事件（pADEs）的发生率。我们的次要目标是确定错误类型、涉及药物的性质以及错误发生的时间。
我们于2015年1月16日至2015年4月20日期间，对一家儿科重症及高依赖病房的患者进行了前瞻性观察性病历审查。审查每位患者的病历，以确定是否存在处方错误或pADE。对每个pADE评估错误类型、所涉及药物的分类、错误的临床严重程度以及错误发生的时间。
我们的研究纳入了41名平均年龄为3.2岁的患者。其中，19名（46.3%）患者至少经历了一次pADE。我们共识别出131起pADE，其中129起为处方错误，即每例受影响患者的错误发生率为6.8次，或每例入住PICU的患者错误发生率为3.1次。研究中发现最常见的错误是剂量计算错误（48.1%），涉及错误的最常见药物为静脉输液（41.7%）、心血管药物（15.0%）和抗感染药物（12.5%）。我们研究中的大多数pADE在临床上要么严重（33.1%）要么显著（44.9%）。几乎每四起错误中就有一起需要监测和/或干预以防止伤害，并且几乎所有（96.9%）的处方错误在到达患者之前就被拦截了。
本研究强调剂量计算错误是儿科重症监护环境中最常见的处方错误。静脉输液、心血管药物和抗感染药物是最常涉及pADE的药物类别。由于所使用药物的高风险性质以及这些患者的危急状况，超过四分之三的pADE被认为在临床上严重或显著地导致了患者伤害。
