Hermanspann Theresa, van der Linden Eva, Schoberer Mark, Fitzner Christina, Orlikowsky Thorsten, Marx Gernot, Eisert Albrecht
Hospital Pharmacy, RWTH Aachen University Hospital, Aachen, Germany,
Department of Pediatric and Adolescent Medicine, Section of Neonatology, RWTH Aachen University Hospital, Aachen, Germany,
Drug Healthc Patient Saf. 2019 Mar 19;11:11-18. doi: 10.2147/DHPS.S184479. eCollection 2019.
To determine the type, frequency, and factors associated with medication preparation and administration errors in adult intensive care units (ICUs) and neonatal ICUs (NICUs)/pediatric ICUs (PICUs).
We conducted a prospective direct observation study in an adult ICU and NICU/PICU in a tertiary university hospital. Between June 2012 and June 2013, a clinical pharmacist and medical student observed the nursing care staff on weekdays during the preparation and administration of intravenous drugs. We analyzed the frequency and type of preparation and administration errors and factors associated with errors.
Six hundred and three preparations in the adult ICU and 281 in the NICU/PICU were observed. Three hundred and eighty-five errors occurred in the adult ICU and 38 in the NICU/PICU. There were 5,040 and 2,514 error opportunities, with overall error rates of 7.6% and 1.5%, respectively. The total opportunities for error meant each single step of preparation and administration that was relevant for the drug. Most errors applied to the category "uniform mixing" (adult ICU: n=227, 59%; NICU/PICU: n=14, 37%). The multivariate logistic regression results showed a significantly different influence of the "preparation type" for the adult ICU compared with the NICU/PICU with regard to the occurrence of an error. Preparations for adult patients of the LCD type (liquid concentrate with diluent into syringe or infusion bag) were more often associated with errors than the P (powder in a glass vial that must be reconstituted and diluted if necessary), =0.012, and LC (liquid concentrate into syringe), =0.002 type.
"Uniform mixing" was the most erroneous preparation step in intravenous drug preparations in two ICUs. Improvement of nurse training and the preparation of prefilled syringes in the pharmacy might reduce errors and improve the quality and safety of drug therapy.
确定成人重症监护病房（ICU）以及新生儿重症监护病房（NICU）/儿科重症监护病房（PICU）中与药物配制和给药错误相关的类型、频率及因素。
我们在一所三级大学医院的成人ICU以及NICU/PICU开展了一项前瞻性直接观察研究。在2012年6月至2013年6月期间，一名临床药剂师和一名医学生在工作日观察护理人员静脉药物的配制和给药过程。我们分析了配制和给药错误的频率及类型以及与错误相关的因素。
观察了成人ICU的603次配制以及NICU/PICU的281次配制。成人ICU发生了385次错误，NICU/PICU发生了38次错误。有5040次和2514次错误机会，总体错误率分别为7.6%和1.5%。错误的总机会是指与药物相关的配制和给药的每一个单独步骤。大多数错误属于“均匀混合”类别（成人ICU：n = 227，59%；NICU/PICU：n = 14，37%）。多因素逻辑回归结果显示，就错误的发生而言，成人ICU与NICU/PICU相比，“配制类型”的影响存在显著差异。成人患者的LCD型（将浓缩液与稀释剂注入注射器或输液袋）配制比P型（玻璃小瓶中的粉末，如有必要必须复溶和稀释），P = 0.012，以及LC型（将浓缩液注入注射器），P = 0.002型更常与错误相关。
“均匀混合”是两个ICU静脉药物配制中错误最多的步骤。加强护士培训以及在药房准备预填充注射器可能会减少错误并提高药物治疗的质量和安全性。
