van der Have M, Dekker D, Theunissen E M J, Snijders C, Kaasjager K A H
Meander Medisch Centrum, afd. Maag-, Darm- en Leverziekten, Amersfoort.
Ned Tijdschr Geneeskd. 2017;161:D1089.
Medication errors are a frequent problem in the accident and emergency (A&E) department.
A 17-year-old boy was referred to our A&E department with an anaphylactic reaction to peanuts. Because of various shortcomings in the care process in A&E, adrenaline was administered intravenously instead of intramuscularly, resulting in a broad complex tachycardia. We analysed these shortcomings using the 'Prevention and recovery information system for monitoring and analysis' (PRISMA) method.
Medication errors are usually a result of shortcomings in non-technical skills, such as communication and situational awareness. Training these skills by applying the concept 'Crew resource management' may reduce medication errors and improve patient safety.
用药错误在急诊部门是一个常见问题。
一名17岁男孩因对花生过敏反应被转诊至我院急诊部。由于急诊护理过程中的各种缺陷，肾上腺素通过静脉注射而非肌肉注射给药，导致宽QRS波心动过速。我们使用“预防与恢复监测分析信息系统”（PRISMA）方法分析了这些缺陷。
用药错误通常是沟通和情景意识等非技术技能缺陷的结果。应用“机组资源管理”概念培训这些技能可能会减少用药错误并提高患者安全。
