Monash University, School of Rural Health, Traralgon, VIC 3844, Australia.
Latrobe Regional Hospital, Traralgon, VIC 3844, Australia.
Int J Qual Health Care. 2021 Feb 20;33(1). doi: 10.1093/intqhc/mzaa136.
Medication errors (MEs) are among the most common types of incidents reported in Australian and international hospitals. There is no uniform method of reporting and reducing these errors. This study aims to identify the incidence, time trends, types and factors associated with MEs in a large regional hospital in Australia.
A 5-year cross-sectional study.
The incidence of MEs was 1.05 per 100 admitted patients. The highest frequency of errors was observed during the colder months of May-August. When distributed by day of the week, Mondays and Tuesdays had the highest frequency of errors. When distributed by hour of the day, time intervals from 7 am to 8 am and from 7 pm to 8 pm showed a sharp increase in the frequency of errors. One thousand and eighty-eight (57.8%) MEs belonged to incidence severity rating (ISR) level 4 and 787 (41.8%) belonged to ISR level 3. There were six incidents of ISR level 2 and only one incident of ISR level 1 reported during the five-year period 2014-2018. Administration-only errors were the most common accounting for 1070 (56.8%) followed by prescribing-only errors (433, 23%). High-risk medications were associated with half the number of errors, the most common of which were narcotics (17.9%) and antimicrobials (13.2%).
MEs continue to be a problem faced by international hospitals. Inexperience of health professionals and nurse-patient ratios might be the fundamental challenges to overcome. Specific training of junior staff in prescribing and administering medication and nurse workload management could be possible solutions to reducing MEs in hospitals.
在澳大利亚和国际医院报告的事件中，用药错误（MEs）是最常见的类型之一。目前还没有统一的报告和减少这些错误的方法。本研究旨在确定澳大利亚一家大型地区医院中 ME 的发生率、时间趋势、类型和相关因素。
一项为期 5 年的横断面研究。
MEs 的发生率为每 100 名入院患者 1.05 例。错误的最高频率发生在 5 月至 8 月较冷的月份。按周几分布时，周一和周二的错误频率最高。按每天的时间分布，上午 7 点到 8 点和晚上 7 点到 8 点之间的时间段错误频率急剧增加。1088 例（57.8%）MEs 属于严重程度分级（ISR）4 级，787 例（41.8%）属于 ISR 3 级。在 2014-2018 年的五年期间，报告了 6 例 ISR 2 级事件，只有 1 例 ISR 1 级事件。仅给药错误最常见，占 1070 例（56.8%），其次是仅处方错误（433 例，23%）。高风险药物与一半的错误相关，最常见的是麻醉剂（17.9%）和抗菌药物（13.2%）。
MEs 仍然是国际医院面临的一个问题。卫生专业人员经验不足和护士与患者比例可能是需要克服的根本挑战。对初级工作人员进行处方和给药以及护士工作量管理方面的特定培训可能是减少医院 ME 的可行解决方案。
