Folli H L, Poole R L, Benitz W E, Russo J C
Pediatrics. 1987 May;79(5):718-22.
The purpose of this study was to record prospectively the frequency of and potential harm caused by errant medication orders at two large pediatric hospitals. The objective of the study was to assess the impact of pharmacist intervention in preventing potential harm. The study was conducted during a 6-month period. A total of 281 and 198 errors were detected at the institutions. The overall error rates for the two hospitals were 1.35 and 1.77 per 100-patient days, and 4.9 and 4.5 per 1,000 medication orders, respectively. Pediatric patients aged 2 years and less and pediatric intensive care unit patients received the greatest proportion of errant orders. Neonatal patients received the lowest rate of errant orders. The most common type of error was incorrect dosage, and the most prevalent type of error was overdosage. Antibiotics was the class of drugs for which errant orders were most common. Orders for theophylline, analgesics, and fluid and electrolytes, including hyperalimentation, were also frequently in error. In general, the error rate was greatest among physicians with the least training, but no physician group was error free. Involving pharmacists in reviewing drug orders significantly reduced the potential harm resulting from errant medication orders.
本研究的目的是前瞻性记录两家大型儿科医院错误医嘱的发生频率及其造成的潜在危害。该研究的目标是评估药剂师干预对预防潜在危害的影响。该研究在6个月期间进行。两家机构共检测到281起和198起错误。两家医院的总体错误率分别为每100个患者日1.35起和1.77起，以及每1000份医嘱4.9起和4.5起。2岁及以下的儿科患者和儿科重症监护病房患者收到的错误医嘱比例最高。新生儿患者收到的错误医嘱率最低。最常见的错误类型是剂量不正确，最普遍的错误类型是用药过量。抗生素是错误医嘱最常见的药物类别。茶碱、镇痛药以及包括胃肠外营养在内的液体和电解质的医嘱也经常出错。一般来说，培训最少的医生的错误率最高，但没有一个医生组是完全无差错的。让药剂师参与审核医嘱显著降低了错误医嘱造成的潜在危害。
