Department of Allergy, Aichi Children's Health and Medical Center, Aichi, Japan; Child Health Center, Aichi Children's Health and Medical Center, Aichi, Japan.
Department of Allergy, Aichi Children's Health and Medical Center, Aichi, Japan.
Allergol Int. 2018 Oct;67(4):475-480. doi: 10.1016/j.alit.2018.02.005. Epub 2018 Mar 5.
The unintentional usage of adrenaline auto-injectors may cause injury to caregivers or patients. To prevent such incidents, we assessed the causative factors of these incidents.
The Anaphylaxis Working Group of the Japanese Society of Pediatric Allergy and Clinical Immunology requested that society members register cases in which adrenaline auto-injectors were unintentionally used. One hundred cases were reported from June 2015 to March 2016. We identified the root causes of 70 child and 25 adult cases, separately.
The incidents occurred with repeated prescriptions as well as the first prescription. Three cases resulted in a failure to administer an adrenaline auto-injector to children with anaphylaxis. Four caregivers used it with improper application (epilepsy or enteritis). Among the child cases, the median age at the time of the incident was 5.5 years (range, 2-14 years). Five children injected the adrenaline auto-injector on their own body trunk. Twenty children were not the allergic patients themselves. Improper management protocol of the device and the child's development were concomitantly involved in most of the cases. A variety of human behaviors were identified as the root causes in the adult cases. At least 34 cases were associated with mix-ups between the actual and training device.
Health workers should provide sufficient education regarding safety use of adrenaline auto-injector for caregivers tailored to their experience levels at both first and repeated prescriptions. Such education must cover anticipatory behavior based on normal child development. Devices should also be further improved to prevent such incidents.
肾上腺素自动注射器的意外使用可能会导致医护人员或患者受伤。为了防止此类事件发生，我们评估了这些事件的原因。
日本儿科过敏和临床免疫学学会过敏工作组要求学会成员登记肾上腺素自动注射器意外使用的病例。从 2015 年 6 月至 2016 年 3 月报告了 100 例。我们分别确定了 70 例儿童和 25 例成人病例的根本原因。
这些事件发生在重复处方和首次处方中。有 3 例因未能对发生过敏反应的儿童使用肾上腺素自动注射器而导致治疗失败。4 名医护人员因不当使用（癫痫或肠炎）而使用。在儿童病例中，事件发生时的中位年龄为 5.5 岁（范围 2-14 岁）。有 5 名儿童将肾上腺素自动注射器自行注射在自己的躯干上。有 20 名儿童本身并非过敏患者。设备管理不当和儿童发育问题同时涉及大多数病例。在成人病例中，各种人为行为被确定为根本原因。至少有 34 例与实际设备和训练设备之间的混淆有关。
医护人员应根据经验水平，为首次和重复处方的医护人员提供有关肾上腺素自动注射器安全使用的充分教育，教育内容必须包括基于正常儿童发育的预期行为。还应进一步改进设备以防止此类事件发生。
Zotero 插件