Ali Sheraz, Aboheimed Nourah Ibrahim, Al-Zaagi Ibrahim Abdulaziz, Al-Dossari Dalal Salem
King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia.
Institute of Biomedicine, University of Eastern Finland, Kuopio, Finland.
Int J Clin Pharm. 2017 Oct;39(5):1004-1007. doi: 10.1007/s11096-017-0514-7. Epub 2017 Jul 26.
Background Medication errors (MEs) are common in health care settings and pose a threat for the hospitalized population. Therefore, aspects of MEs were explored in a tertiary setting serving a diverse population. Objective To examine the occurrence, severity and reporting of MEs in hospitalized patients. Methods This retrospective analysis included 10,683 ME report forms that were received by the Medication Safety Unit of King Saud Medical City (KSMC) in 2015. ME outcomes were determined according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for categorizing MEs algorithm. Results A total of 13,677 MEs in 912,500 prescriptions were reported. The incidence rate of MEs was 1.5% (13,677/912,500). The highest percentage (42.2%) of MEs occurred during the transcription stage, and 70.0% of MEs were reported as near misses. Wrong frequency and wrong concentration accounted for nearly half of the MEs. Conclusion We found 1.5 MEs per 100 prescriptions; more than two-thirds of the MEs were preventable and were intercepted before reaching the patients. Most MEs reported by pharmacists occurred at the transcription stage while wrong frequency was the most common error type encountered. Further studies should explore the clinical consequences of MEs at a healthcare institution.
背景 用药错误（MEs）在医疗环境中很常见，对住院患者构成威胁。因此，在为不同人群服务的三级医疗机构中对用药错误的各个方面进行了探讨。目的 研究住院患者用药错误的发生率、严重程度及上报情况。方法 这项回顾性分析纳入了沙特国王医疗城（KSMC）药物安全部门在2015年收到的10683份用药错误报告表。用药错误结果根据国家用药错误报告和预防协调委员会（NCC MERP）的用药错误分类索引算法来确定。结果 在912500张处方中总共报告了13677起用药错误。用药错误发生率为1.5%（13677/912500）。用药错误发生率最高的阶段是转录阶段（42.2%），70.0%的用药错误报告为险些酿成的错误。用药频率错误和浓度错误占用药错误的近一半。结论 我们发现每100张处方中有1.5起用药错误；超过三分之二的用药错误是可预防的，并且在到达患者之前就被拦截了。药剂师报告的大多数用药错误发生在转录阶段，而用药频率错误是最常见的错误类型。进一步的研究应探讨医疗机构中用药错误的临床后果。
