Medicines Evaluation Board, Utrecht, The Netherlands.
Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands.
Drug Saf. 2020 Jan;43(1):45-55. doi: 10.1007/s40264-019-00874-7.
Medication errors can have serious consequences for patients. To prevent the occurrence of medication errors in clinical practice, safety concerns may be included in the risk management plan and subsequently be addressed with routine and/or additional risk minimisation measures.
This study aims to describe safety concerns around medication errors and the risk minimisation measures for centrally authorised products in the European Union.
All safety concerns included in the risk management plans of originator centrally authorised products, authorised between 1 January, 2010 and 31 December, 2017, were collected from the European Public Assessment Report registry. Medication error safety concerns were categorised by Anatomical Therapeutic Classification code, year of authorisation, type of medication error and type of risk minimisation measure.
During the study period, 311 centrally authorised products were approved, of which 84 had at least one medication error safety concern. The proportion of centrally authorised products with medication error safety concerns showed variation between 2010 and 2017 ranging from 15.2% to 36.4%. In total, 95 medication error safety concerns were identified. The type of medication error was highly variable, drug administration error was listed most frequently (n = 17). For 27 out of 95 medication error safety concerns, corresponding to 23 centrally authorised products, additional risk minimisation measures were required. All additional risk minimisation measures consisted of educational material targeted at healthcare professionals (85.2%) and/or patients (51.9%). For 78.3% of centrally authorised products with additional risk minimisation measures for medication errors, studies to evaluate the effectiveness of the additional risk minimisation measures were agreed upon.
Medication error safety concerns were listed for almost a quarter of centrally authorised products approved during the study period. Further research is needed to evaluate the effectiveness and continued need for additional risk minimisation measures for medication errors.
药物错误可能对患者造成严重后果。为了在临床实践中预防药物错误的发生,可以将安全问题纳入风险管理计划,并随后通过常规和/或额外的风险最小化措施来解决。
本研究旨在描述欧盟中集中授权产品的药物错误安全问题和风险最小化措施。
从欧洲公共评估报告登记处收集了 2010 年 1 月 1 日至 2017 年 12 月 31 日期间批准的原研集中授权产品的风险管理计划中包含的所有安全问题。根据解剖治疗学分类代码、授权年份、药物错误类型和风险最小化措施类型对药物错误安全问题进行分类。
在研究期间,批准了 311 种集中授权产品,其中 84 种产品至少有一个药物错误安全问题。在 2010 年至 2017 年期间,具有药物错误安全问题的集中授权产品的比例存在差异,范围从 15.2%到 36.4%。总共确定了 95 个药物错误安全问题。药物错误的类型差异很大,药物给药错误最为常见(n=17)。对于 27 个药物错误安全问题(涉及 23 种集中授权产品),需要采取额外的风险最小化措施。所有额外的风险最小化措施均包括针对医疗保健专业人员(85.2%)和/或患者(51.9%)的教育材料。对于有额外风险最小化措施的药物错误的集中授权产品的 78.3%,同意进行评估额外风险最小化措施有效性的研究。
在研究期间批准的集中授权产品中,近四分之一列出了药物错误安全问题。需要进一步研究来评估药物错误的额外风险最小化措施的有效性和持续需求。