Servicio de Farmacia, Hospital Universitario Ramón y Cajal, Madrid, Spain.
Departamento de Farmacología, Farmacognosia y Botánica, Facultad de Farmacia, Universidad Complutense, Madrid, Spain.
J Eval Clin Pract. 2021 Feb;27(1):160-166. doi: 10.1111/jep.13407. Epub 2020 May 5.
To analyse the impact of a set of measures designed by a working group to reduce medication errors (MEs) during the care transition of elderly trauma patients. The secondary objectives were to classify MEs and determine their location.
A 43-month pre-post prospective intervention study in a university hospital. A working group was set up in the Trauma Service. A pharmacist analysed the pharmacotherapeutic processes of all patients admitted to the Trauma Service in different healthcare locations from Monday to Friday. To detect MEs, the pharmacist reviewed this process at the following points: reconciliation, prescription, validation, dispensing, and administration records. Errors were classified according to the Ruiz Jarabo classification. Subsequently, the working group designed a set of measures that were implemented with the incorporation into the Acute Care Team and the intervention of a pharmacist. Data on MEs were again collected in a post-implementation phase.
There was a statistically significant reduction in MEs between phases. A total of 132 (31.3%) patients experienced MEs during the pre-implementation phase and 75 (16.2%) during the post-implementation phase. Among the measures implemented, the incorporation of the pharmacist to the team, as well as training sessions and design of medication protocols. During the pre-implementation and post-implementation phases, the ME rates were respectively as follows: reconciliation 31.6% (172) vs 14.8% (91); prescription 7.7% (79) vs 1.9% (23); dispensing 1% (10) vs 0.3% (3); administration record 0.4% (4) vs 0.0% (0); and validation 0.3% (3) vs 0.1% (1). There were significant reductions in reconciliation, prescription, and dispensing errors. The majority of the MEs occurred in the Trauma Service.
The implementation of specific measures by a Multidisciplinary Safety Group reduced MEs in the care transition of elderly trauma patients, particularly those MEs that occurred during reconciliation. The greatest reduction in MEs occurred in the Trauma Service.
分析一组由工作组设计的旨在减少老年创伤患者护理交接期间用药错误（MEs）的措施的影响。次要目标是对 MEs 进行分类并确定其位置。
这是一项在大学医院进行的为期 43 个月的前瞻性干预研究。在创伤科成立了一个工作组。一名药剂师分析了每周一至周五在不同医疗地点收治到创伤科的所有患者的药物治疗过程。为了发现 MEs，药剂师在以下几个点回顾了这个过程：核对、处方、验证、配药和给药记录。根据 Ruiz Jarabo 分类对错误进行分类。随后，工作组设计了一组措施，在将药剂师纳入急性护理团队并进行干预的情况下实施。在实施后阶段再次收集关于 MEs 的数据。
在实施前后两个阶段之间，MEs 数量有统计学显著减少。在实施前阶段，共有 132 名（31.3%）患者出现 MEs，而在实施后阶段则有 75 名（16.2%）患者出现 MEs。在所实施的措施中，药剂师加入团队、培训课程和设计用药方案都起到了作用。在实施前和实施后阶段，ME 发生率分别如下：核对 31.6%（172）与 14.8%（91）；处方 7.7%（79）与 1.9%（23）；配药 1%（10）与 0.3%（3）；给药记录 0.4%（4）与 0.0%（0）；验证 0.3%（3）与 0.1%（1）。核对、处方和配药错误明显减少。大多数 MEs 发生在创伤科。
多学科安全小组实施的具体措施减少了老年创伤患者护理交接期间的 MEs，特别是那些在核对过程中发生的 MEs。MEs 减少最多的是在创伤科。
