Dufay Edith, Morice Sophie, Dony Alexandre, Baum Thomas, Doerper Sébastien, Rauss Alain, Piney David
Pôle de Logistique Médicale, Service de pharmacie, Centre Hospitalier de Lunéville, Lunéville, France.
Service de pharmacie, Centre Hospitalier Universitaire de Nancy, Nancy, France.
Eur J Hosp Pharm. 2016 Jul;23(4):207-212. doi: 10.1136/ejhpharm-2015-000745. Epub 2015 Dec 16.
This study was designed to assess the clinical impact of medication reconciliation using two criteria: the number of inpatients who had experienced at least one medication error; the severity of the potential harm associated with these detected errors.
The study was a prospective observational one. The eligible population included patients aged 65 and over subjected to medication reconciliation at admission. The potential severity of medication errors was evaluated independently by the physician in charge of the patient and by the pharmacist involved in the medication reconciliation process. Severity assessment took account of the drug(s) involved in the error, the type of medication error, and the patient's clinical and biological data.
From January 2011 to September 2012, 1799 medication errors were recorded among the 1670 patients subjected to medication reconciliation who were hospitalised from the emergency department. At least one medication error occurred for 744 (44.6%) of these patients. There were 87 medication errors associated with potentially major severity (5.6%). These concerned 67 patients (4.2%). The most prevalent error was omission. Cardiovascular and anticoagulant drugs were the drugs most frequently involved in these serious medication errors. Arrhythmia, haemorrhage, thrombosis, hyperglycaemia and hypoglycaemia were identified as the most likely harms that could have occurred.
The detection of cases of serious potential harm shows the clinical impact of medication reconciliation. It would be interesting to perform a multicentred assessment using indicators such as the number of inpatients experiencing at least one serious medication error. This could help to promote medication reconciliation as essential for patient safety.
本研究旨在使用两个标准评估用药核对的临床影响：经历过至少一次用药错误的住院患者数量；与这些检测到的错误相关的潜在危害的严重程度。
该研究为前瞻性观察性研究。符合条件的人群包括65岁及以上入院时接受用药核对的患者。负责患者的医生和参与用药核对过程的药剂师独立评估用药错误的潜在严重程度。严重程度评估考虑了错误中涉及的药物、用药错误的类型以及患者的临床和生物学数据。
2011年1月至2012年9月，在1670例从急诊科入院并接受用药核对的患者中记录到1799例用药错误。其中744例（44.6%）患者至少发生了一次用药错误。有87例用药错误与潜在的重大严重程度相关（5.6%）。这些错误涉及67例患者（4.2%）。最常见的错误是遗漏。心血管药物和抗凝药物是这些严重用药错误中最常涉及的药物。心律失常、出血、血栓形成、高血糖和低血糖被确定为最可能发生的危害。
严重潜在危害病例的检测显示了用药核对的临床影响。使用经历过至少一次严重用药错误的住院患者数量等指标进行多中心评估将会很有意思。这有助于推动用药核对，将其视为保障患者安全的关键措施。
