Institute of Clinical Sciences, University of Birmingham, Birmingham, UK.
West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, B18 7QH, UK.
Drug Saf. 2018 Jan;41(1):103-110. doi: 10.1007/s40264-017-0588-0.
Since legislation in 2009, coroners in England and Wales must make reports in cases where they believe it is possible to prevent future deaths. We categorised the reports and examined whether they could reveal preventable medication errors or novel adverse drug reactions.
We examined 500 coroners' reports by pre-defined criteria to identify those in which medicines played a part, and to collect information on coroners' concerns.
We identified 99 reports (100 deaths) in which medicines or a part of the medication process or both were mentioned. Reports mentioned anticoagulants (22 reports), opioids (17), antidepressants (17), drugs of abuse excluding opioids (12 deaths) and other drugs. The most important concerns related to adverse reactions to prescribed medicines (22), omission of necessary treatment (21), failure to monitor treatment (17) and poor systems (17). These were related to defects in education or training, lack of clear guidelines or protocols and failure to implement existing guidelines, among other reasons. Most reports went either to NHS Hospital Trusts or to local trusts. The responses of addressees were rarely published. We identified four safety warnings from the Medicines and Healthcare Products Regulatory Agency that were based on coroners' warnings.
Coroners' reports to prevent future deaths provide some information on medication errors and adverse reactions. They rarely identify new hazards. At present they are often addressed to local bodies, but this could mean that wider lessons are lost.
自 2009 年立法以来，英格兰和威尔士的验尸官必须在他们认为有可能防止未来死亡的情况下编写报告。我们对报告进行了分类，并检查了它们是否可以揭示可预防的用药错误或新的药物不良反应。
我们通过预定义的标准检查了 500 份验尸官报告，以确定其中涉及药物的报告，并收集有关验尸官关注的信息。
我们确定了 99 份报告（涉及 100 例死亡），其中提到了药物或部分药物过程或两者。报告中提到了抗凝剂（22 份报告）、阿片类药物（17 份）、抗抑郁药（17 份）、除阿片类药物以外的滥用药物（12 例死亡）和其他药物。最重要的关注点与处方药物的不良反应（22 例）、遗漏必要治疗（21 例）、未能监测治疗（17 例）和不良系统（17 例）有关。这些与教育或培训缺陷、缺乏明确的指南或方案以及未能实施现有指南等有关。大多数报告都寄往 NHS 医院信托或地方信托。收件人的回应很少公布。我们从药品和保健产品监管局（Medicines and Healthcare Products Regulatory Agency）确定了四条基于验尸官警告的安全警告。
防止未来死亡的验尸官报告提供了一些关于用药错误和不良反应的信息。它们很少发现新的危害。目前，它们通常被寄往地方机构，但这可能意味着更广泛的教训丢失了。
