Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PT, UK.
Health Information Technology Department, Faculty of Applied Studies, King Abdul Aziz University, Jeddah, 21589, Kingdom of Saudi Arabia.
Paediatr Drugs. 2021 May;23(3):287-297. doi: 10.1007/s40272-021-00442-6. Epub 2021 Apr 8.
Critically ill neonates and paediatric patients may be at a greater risk of medication-related safety incidents than those in other clinical areas.
This study aimed to examine the nature of, and contributory factors associated with, medication-related safety incidents reported in neonatal and paediatric intensive care units (ICUs).
We carried out a mixed-methods analysis of anonymised medication safety incidents reported to the National Reporting and Learning System that involved children (aged ≤ 18 years) admitted to ICUs across England and Wales over a 9-year period (2010-2018). Data were analysed descriptively, and free-text descriptions of harmful incidents were examined to explore potential contributory factors associated with incidents.
In total, 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during the medicines administration (n = 13,668 [53.5%]) and prescribing stages (n = 7412 [29%]). The most commonly implicated error types were drug omission (n = 4812 [18.8%]) and dosing errors (n = 4475 [17.5%]). Neonates were commonly involved in reported incidents (n = 12,235 [47.9%]). Anti-infectives (n = 6483 [25.4%]) were the medications most commonly associated with incidents and commonly involved neonates. Incidents that were reported to have caused patient harm accounted for 12.2% (n = 3129) and commonly involved neonates (n = 1570/3129 [50.2%]). Common contributing factors to harmful incidents included staff-related factors (68.7%), such as failure to follow protocols or errors in documentation, which were often associated with working conditions, inadequate guidelines, and design of systems and protocols.
Neonates were commonly involved in medication-related incidents reported in children's intensive care settings. Improvements in staffing and workload, design of systems and processes, and the use of anti-infective medications may reduce this risk.
危重病新生儿和儿科患者发生与药物相关的安全事件的风险可能高于其他临床领域的患者。
本研究旨在检查在新生儿和儿科重症监护病房（ICU）报告的与药物相关的安全事件的性质和相关因素。
我们对英格兰和威尔士 9 年来（2010-2018 年）向国家报告和学习系统报告的涉及儿童（年龄≤18 岁）的匿名药物安全事件进行了混合方法分析。数据进行了描述性分析，并对有害事件的自由文本描述进行了检查，以探讨与事件相关的潜在促成因素。
共检查了 25567 份符合条件的与药物相关的事件报告。事件通常发生在药物管理（n=13668[53.5%]）和处方阶段（n=7412[29%]）。最常见的错误类型是药物漏用（n=4812[18.8%]）和剂量错误（n=4475[17.5%]）。报告的事件中经常涉及新生儿（n=12235[47.9%]）。抗感染药物（n=6483[25.4%]）是与事件最常相关的药物，且经常涉及新生儿。报告造成患者伤害的事件占 12.2%（n=3129），且经常涉及新生儿（n=1570/3129[50.2%]）。有害事件的常见促成因素包括与员工相关的因素（68.7%），例如未能遵循协议或记录错误，这些因素通常与工作条件、指南不足以及系统和协议的设计有关。
新生儿经常参与儿童重症监护病房报告的与药物相关的事件。改善人员配备和工作量、系统和流程设计以及抗感染药物的使用可能会降低这种风险。
