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癌症治疗中的用药错误:2008年至2019年德国医院药剂师的报告

Medication errors in cancer therapy: Reports from German hospital pharmacists between 2008 and 2019.

作者信息

Weber Lisa, Langebrake Claudia, Picksak Gesine, Schöning Tilman, Schulze Ingo, Jaehde Ulrich

机构信息

Hospital Pharmacy of the University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany.

Hospital Pharmacy of the University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.

出版信息

J Oncol Pharm Pract. 2023 Sep;29(6):1443-1453. doi: 10.1177/10781552221135130. Epub 2022 Nov 8.

Abstract

OBJECTIVE

Since medication errors can have severe consequences, the development of methods to improve patient safety is becoming increasingly important. The aim of this evaluation was to identify frequent medication errors in oncology as well as characteristic correlations in the various error patterns. In addition, the implementation rate of the proposed pharmaceutical intervention was determined in order to assess the benefit of a clinical pharmacist in the field of oncology.

METHODS

The evaluation was based on a data-set from a national documentation system for medication errors and interventions (DokuPIK) used by hospital pharmacists in the field of oncology from 2008 to 2019, namely 6684 reported cases in oncology, representing about 5% of all reports in DokuPIK.

RESULTS

The most frequently reported errors were incorrect doses (22% of reported errors), followed by interactions (14%); in 10% of errors the prescription/documentation was incomplete/incorrect. The intervention suggested by the pharmacist was implemented in 97% of the cases. Based on the respective Anatomical Therapeutical Chemical Classification (ATC codes), drugs (or groups of drugs) were identified that were reported frequently in connection with medication errors, namely carboplatin and cyclophosphamide as anticancer drugs pantoprazole as non-anticancer drug.

CONCLUSION

Frequently occurring medication errors in the field of oncology were identified, facilitating the development of specific recommendations for action and prevention strategies. The implementation of an electronic prescription software is particularly recommended for the avoidance of dosage errors in chemotherapy.

摘要

目的

由于用药错误可能会造成严重后果,开发提高患者安全的方法变得越来越重要。本评估的目的是确定肿瘤学中常见的用药错误以及各种错误模式中的特征性关联。此外,确定所提议的药物干预措施的实施率,以评估临床药剂师在肿瘤学领域的作用。

方法

该评估基于2008年至2019年肿瘤学领域医院药剂师使用的国家用药错误及干预措施文档系统(DokuPIK)中的数据集,即肿瘤学领域报告的6684例病例,约占DokuPIK所有报告的5%。

结果

报告最多的错误是剂量不正确(占报告错误的22%),其次是相互作用(14%);10%的错误中处方/文档不完整/不正确。药剂师建议的干预措施在97%的病例中得到实施。根据各自的解剖治疗化学分类(ATC代码),确定了与用药错误经常相关的药物(或药物组),即作为抗癌药物的卡铂和环磷酰胺,作为非抗癌药物的泮托拉唑。

结论

确定了肿瘤学领域中经常发生的用药错误,有助于制定具体的行动建议和预防策略。特别建议实施电子处方软件以避免化疗中的剂量错误。

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