Chua Siew-Siang, Choo Sim-Mei, Sulaiman Che Zuraini, Omar Asma, Thong Meow-Keong
Department of Pharmacy, Faculty of Medicine, University of Malaya.
Pharmacy Department, University Malaya Medical Centre.
Ther Clin Risk Manag. 2017 Mar 23;13:345-353. doi: 10.2147/TCRM.S128504. eCollection 2017.
Drug administration errors are more likely to reach the patient than other medication errors. The main aim of this study was to determine whether the sharing of information on drug administration errors among health care providers would reduce such problems.
This study involved direct, undisguised observations of drug administrations in two pediatric wards of a major teaching hospital in Kuala Lumpur, Malaysia. This study consisted of two phases: Phase 1 (pre-intervention) and Phase 2 (post-intervention). Data were collected by two observers over a 40-day period in both Phase 1 and Phase 2 of the study. Both observers were pharmacy graduates: Observer 1 just completed her undergraduate pharmacy degree, whereas Observer 2 was doing her one-year internship as a provisionally registered pharmacist in the hospital under study. A drug administration error was defined as a discrepancy between the drug regimen received by the patient and that intended by the prescriber and also drug administration procedures that did not follow standard hospital policies and procedures. Results from Phase 1 of the study were analyzed, presented and discussed with the ward staff before commencement of data collection in Phase 2.
A total of 1,284 and 1,401 doses of drugs were administered in Phase 1 and Phase 2, respectively. The rate of drug administration errors reduced significantly from Phase 1 to Phase 2 (44.3% versus 28.6%, respectively; <0.001). Logistic regression analysis showed that the adjusted odds of drug administration errors in Phase 1 of the study were almost three times that in Phase 2 (<0.001). The most common types of errors were incorrect administration technique and incorrect drug preparation. Nasogastric and intravenous routes of drug administration contributed significantly to the rate of drug administration errors.
This study showed that sharing of the types of errors that had occurred was significantly associated with a reduction in drug administration errors.
给药错误比其他用药错误更有可能影响到患者。本研究的主要目的是确定医疗保健提供者之间分享给药错误信息是否会减少此类问题。
本研究对马来西亚吉隆坡一家大型教学医院的两个儿科病房的给药情况进行了直接、无掩饰的观察。本研究包括两个阶段：第1阶段（干预前）和第2阶段（干预后）。在研究的第1阶段和第2阶段，由两名观察者在40天的时间内收集数据。两名观察者均为药学专业毕业生：观察者1刚完成本科药学学位，而观察者2正在该研究医院作为临时注册药剂师进行为期一年的实习。给药错误被定义为患者接受的药物治疗方案与开处方者意图的方案之间的差异，以及未遵循医院标准政策和程序的给药程序。在第2阶段开始收集数据之前，对研究第1阶段的结果进行了分析、呈现并与病房工作人员进行了讨论。
第1阶段和第2阶段分别给药1284剂和1401剂。从第1阶段到第2阶段，给药错误率显著降低（分别为44.3%和28.6%；<0.001）。逻辑回归分析表明，研究第1阶段给药错误的调整后几率几乎是第2阶段的三倍（<0.001）。最常见的错误类型是给药技术不正确和药物配制不正确。鼻胃管和静脉给药途径对给药错误率有显著影响。
本研究表明，分享已发生的错误类型与减少给药错误显著相关。
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