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沙特阿拉伯用药错误现状:一项全国性观察研究。

Current Situation of Medication Errors in Saudi Arabia: A Nationwide Observational Study.

机构信息

Regional Drug Information and Pharmacovigilance Center, Ministry of Health.

Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk.

出版信息

J Patient Saf. 2022 Mar 1;18(2):e448-e453. doi: 10.1097/PTS.0000000000000839.

Abstract

OBJECTIVES

Medication errors are common and highly preventable events that significantly affect patients' health. This nationwide study primarily aims to quantify the rate and level of harm from the reported medication errors and to determine the medication process stages in which the reported errors occurred.

METHODS

This retrospective observational study concerns medication errors reported to the General Department of Pharmaceutical Care database from March 2018 to June 2019. The database stores all aspects of medication error information, including patient, medication, and error information, along with the job position of the staff involved and contributing factors. The medication use process was categorized into these stages: ordering/prescribing, transcribing, dispensing, administering, and monitoring. We recorded each medication error based on categories from the U.S. National Coordinating Council for Medication Error Reporting and Prevention.

RESULTS

A total of 71,332 medication error events were reported to the database. Physicians made 63,120 (88.5%) reported errors, and pharmacists most frequently detected the errors (75.9%). The majority of reported errors appeared at the prescribing phase (84.8%), followed by the transcribing (5.8%) and dispensing (5.7%) phases. A total of 4182 (5.8%) errors reached the patient. Health care professionals' work overload and lack of experience were associated with 31.6% and 22.7% of the reported errors, respectively.

CONCLUSIONS

Our study highlights the concern regarding medication errors and their low reporting by indicating that pharmacists reported and detected the majority of errors. Promoting a no-blame culture and education for health professionals is vital for improving the error-reporting rate.

摘要

目的

药物错误是常见且可高度预防的事件,会对患者的健康产生重大影响。本项全国性研究主要旨在量化报告的药物错误的发生率和严重程度,并确定报告的错误发生在药物处理的哪个阶段。

方法

本回顾性观察性研究涉及 2018 年 3 月至 2019 年 6 月向药剂科药物护理数据库报告的药物错误。该数据库存储药物错误信息的各个方面,包括患者、药物和错误信息,以及涉及的工作人员的职位和促成因素。药物使用过程分为以下阶段:医嘱/处方、转录、配药、给药和监测。我们根据美国国家药物错误报告和预防协调委员会的类别记录了每个药物错误。

结果

共向数据库报告了 71332 例药物错误事件。医生报告了 63120(88.5%)例错误,药剂师最常发现错误(75.9%)。报告的错误大多出现在处方阶段(84.8%),其次是转录(5.8%)和配药(5.7%)阶段。共有 4182(5.8%)例错误到达患者。医护人员工作负荷过重和经验不足分别与 31.6%和 22.7%的报告错误有关。

结论

我们的研究表明,药剂师报告和发现了大多数错误,这表明药物错误及其低报告率令人担忧。促进无责文化和对卫生专业人员的教育对于提高错误报告率至关重要。

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