Chalasani Sri Harsha, Ramesh Madhan, Gurumurthy Parthasarathi
Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education and Research, Mysuru 570015, Karnataka, India.
Dean-Global Engagement, JSS Academy of Higher Education and Research, Mysuru 570015, Karnataka, India.
Pharmacy (Basel). 2018 Dec 14;6(4):133. doi: 10.3390/pharmacy6040133.
Medication errors (MEs) often prelude guilt and fear in health care professionals (HCPs), thereby resulting in under-reporting and further compromising patient safety. To improve patient safety, we conducted a study on the implementation of a voluntary medication error-reporting and monitoring programme. The ME reporting system was established using the principles based on prospective, voluntary, open, anonymous, and stand-alone surveillance in a tertiary care teaching hospital located in South India. A prospective observational study was carried out for three years and a voluntary Medication Error-reporting Form was developed to report medication errors MEs that had occurred in patients of either sex were included in the study, and the reporters were given the choice to remain anonymous. The analysis was carried out and discussed with HCPs to minimise the recurrence. A total of 1310 medication errors were reported among 20,256 hospitalised patients and the incidence was 6.4%. Common aetiologies were administration errors [501 (38.2%)], followed by prescribing and transcribing errors [363 (28%)]. Root-cause of these MEs were distractions, workload, and communications. Analgesics/antipyretics (19.4%) and antibiotics (15.7%) were the most commonly implicated classes of medications. A clinical pharmacist initiated non-punitive anonymous ME reporting system could improve patient safety.
用药错误（MEs）常常使医疗保健专业人员（HCPs）产生内疚和恐惧，从而导致报告不足，进一步危及患者安全。为提高患者安全，我们开展了一项关于实施自愿性用药错误报告和监测计划的研究。在印度南部一家三级护理教学医院，依据前瞻性、自愿性、开放性、匿名性和独立监测原则建立了用药错误报告系统。进行了为期三年的前瞻性观察研究，并制定了一份自愿性用药错误报告表，用于报告在任何性别患者中发生的用药错误。纳入研究的患者发生用药错误后，报告者可选择匿名。对研究结果进行了分析，并与医疗保健专业人员进行了讨论，以尽量减少用药错误的再次发生。在20256名住院患者中共报告了1310起用药错误，发生率为6.4%。常见病因是给药错误[501起（38.2%）]，其次是处方和抄写错误[363起（28%）]。这些用药错误的根本原因是注意力分散、工作量和沟通问题。镇痛药/退热药（19.4%）和抗生素（15.7%）是最常涉及的药物类别。临床药师发起的非惩罚性匿名用药错误报告系统可提高患者安全。
