Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 CN, Rotterdam, The Netherlands.
Department of Hospital Pharmacy, Reinier de Graaf Hospital, 2625 AD, Delft, The Netherlands.
Int J Qual Health Care. 2019 Jun 1;31(5):346-352. doi: 10.1093/intqhc/mzy177.
To assess the proportion of all medication error reports in hospitals and primary care that involved an anticoagulant. Secondary objectives were the anticoagulant involved, phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. Additional secondary objectives were the total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month and the proportion of causes of 1000 anticoagulant medication errors (comparing the pre- and post-guideline phase).
A cross-sectional study.
Medication errors reported to the Central Medication incidents Registration reporting system.
Between December 2012 and May 2015, 42 962 medication errors were reported to the CMR.
N/A.
Proportion of all medication error reports that involved an anticoagulant. Phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. The total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month (comparing the pre- and post-guideline phase) and the total number of causes of 1000 anticoagulant medication errors before and after introduction of the LSKA 2.0 guideline.
Anticoagulants were involved in 8.3% of the medication error reports. A random selection of 1000 anticoagulant medication error reports revealed that low-molecular weight heparins were most often involved in the error reports (56.2%). Most reports concerned the prescribing phase of the medication process (37.1%) and human factors were the leading cause of medication errors mentioned in the reports (53.4%). Publication of the national guideline on integrated antithrombotic care had no effect on the proportion of anticoagulant medication error reports. Human factors were the leading cause of medication errors before and after publication of the guideline.
Anticoagulant medication errors occurred in 8.3% of all medication errors. Most error reports concerned the prescribing phase of the medication process. Leading cause was human factors. The publication of the guideline had no effect on the proportion of anticoagulant medication errors.
评估医院和初级保健中所有药物错误报告中涉及抗凝剂的比例。次要目标是涉及的抗凝剂、药物错误发生的药物治疗过程阶段、1000 例抗凝药物错误的原因和后果。其他次要目标是每月每 1000 例抗凝药物错误报告的总数，除以每月药物错误报告的总数和 1000 例抗凝药物错误的原因比例（比较指南前后阶段）。
横断面研究。
向中央药物事件登记报告系统报告的药物错误。
2012 年 12 月至 2015 年 5 月，向 CMR 报告了 42962 例药物错误。
无。
涉及抗凝剂的所有药物错误报告的比例。药物错误发生的药物治疗过程阶段、1000 例抗凝药物错误的原因和后果。每月抗凝药物错误报告的总数，除以每月药物错误报告的总数（比较指南前后阶段）和引入 LSKA 2.0 指南前后 1000 例抗凝药物错误的总原因。
抗凝剂在 8.3%的药物错误报告中涉及。随机选择的 1000 例抗凝药物错误报告显示，低分子量肝素最常涉及错误报告（56.2%）。大多数报告涉及药物治疗过程的处方阶段（37.1%），人为因素是报告中提到的药物错误的主要原因（53.4%）。国家综合抗血栓治疗指南的发布对抗凝药物错误报告的比例没有影响。人为因素是指南发布前后药物错误的主要原因。
抗凝药物错误在所有药物错误中占 8.3%。大多数错误报告涉及药物治疗过程的处方阶段。主要原因是人为因素。指南的发布对抗凝药物错误的比例没有影响。
