Department of Surgery and Cancer, Division of Surgery, Imperial College London, London, London, UK
NIHR-Imperial Patient Safety Translational Research Centre, Imperial College London, London, London, UK.
BMJ Open. 2019 Nov 25;9(11):e032686. doi: 10.1136/bmjopen-2019-032686.
Medication errors during paediatric resuscitation are thought to be common. However, there is little evidence about the individual process steps that contribute to such medication errors in this context.
To describe the incidence, nature and severity of medication errors in simulated paediatric resuscitations, and to employ human reliability analysis to understand the contribution of discrepancies in individual process steps to the occurrence of these errors.
We conducted a prospective observational study of simulated resuscitations subjected to video microanalysis, identification of medication errors, severity assessment and human reliability analysis in a large English teaching hospital. Fifteen resuscitation teams of two doctors and two nurses each conducted one of two simulated paediatric resuscitation scenarios.
At least one medication error was observed in every simulated case, and a large magnitude (>25% discrepant) or clinically significant error in 11 of 15 cases. Medication errors were observed in 29% of 180 simulated medication administrations, 40% of which considered to be moderate or severe. These errors were the result of 884 observed discrepancies at a number of steps in the drug ordering, preparation and administration stages of medication use, 8% of which made a major contribution to a resultant medication error. Most errors were introduced by discrepancies during drug preparation and administration.
Medication errors were common with a considerable proportion likely to result in patient harm. There is an urgent need to optimise existing systems and to commission research into new approaches to increase the reliability of human interactions during administration of medication in the paediatric emergency setting.
在儿科复苏过程中，人们认为用药错误很常见。然而，关于导致这种用药错误的个别过程步骤，在这方面几乎没有证据。
描述模拟儿科复苏中用药错误的发生率、性质和严重程度，并运用人为可靠性分析来了解个体过程步骤中的差异对这些错误发生的影响。
我们在一家大型英语教学医院进行了一项前瞻性观察研究，对视频微分析、用药错误识别、严重程度评估和人为可靠性分析进行模拟复苏。由两个医生和两个护士组成的 15 个复苏小组进行了两个模拟儿科复苏场景中的一个。
每个模拟病例中至少观察到一个用药错误，15 个病例中有 11 个存在较大幅度（>25%差异）或临床显著错误。在 180 次模拟用药管理中观察到 29%的用药错误，其中 40%被认为是中度或重度。这些错误是在药物订购、准备和管理阶段的多个步骤中观察到的 884 个差异的结果，其中 8%的差异对最终用药错误有重大影响。大多数错误是在药物准备和管理过程中的差异引起的。
用药错误很常见，其中相当一部分可能导致患者伤害。迫切需要优化现有系统，并委托研究新方法，以提高儿科急救环境中给药过程中人为交互的可靠性。
