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One week in the life of my anesthetic cart's medication drawer or: drug errors-what (else) will it take to change the system?

作者信息

Schwarz Stephan K W

机构信息

Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada.

Department of Anesthesia, St. Paul's Hospital/Providence Health Care, 3rd Floor, Providence Bldg., 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.

出版信息

Can J Anaesth. 2023 May;70(5):805-810. doi: 10.1007/s12630-023-02437-y. Epub 2023 Mar 14.

DOI:10.1007/s12630-023-02437-y
PMID:36918455
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10013988/
Abstract
摘要
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8fcd/10013988/800cb1056d96/12630_2023_2437_Fig2_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8fcd/10013988/c762ac706ee0/12630_2023_2437_Fig1_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8fcd/10013988/800cb1056d96/12630_2023_2437_Fig2_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8fcd/10013988/c762ac706ee0/12630_2023_2437_Fig1_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/8fcd/10013988/800cb1056d96/12630_2023_2437_Fig2_HTML.jpg

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One week in the life of my anesthetic cart's medication drawer or: drug errors-what (else) will it take to change the system?麻醉推车上药品抽屉一周见闻，或曰：用药差错——改变系统还需要什么（其他因素）？
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Accidental administration of tranexamic acid into the epidural space: a case report.意外将氨甲环酸注入硬膜外腔：病例报告。
Can J Anaesth. 2022 Sep;69(9):1169-1173. doi: 10.1007/s12630-022-02276-3. Epub 2022 Jun 25.
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Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia.蛛网膜下腔麻醉期间使用氨甲环酸导致的灾难性药物差错。
Anaesthesia. 2019 Jul;74(7):904-914. doi: 10.1111/anae.14662. Epub 2019 Apr 15.
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Death and Neurological Devastation From Intrathecal Vinca Alkaloids.鞘内注射长春花生物碱导致的死亡和神经功能损害
P T. 2016 Aug;41(8):464-525.
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Drug errors: consequences, mechanisms, and avoidance.药物错误：后果、机制与防范。
Br J Anaesth. 2010 Jul;105(1):76-82. doi: 10.1093/bja/aeq131. Epub 2010 May 27.
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Evidence-based strategies for preventing drug administration errors during anaesthesia.麻醉期间预防给药错误的循证策略。
Anaesthesia. 2004 May;59(5):493-504. doi: 10.1111/j.1365-2044.2004.03670.x.
6
Medication errors in anesthetic practice: a survey of 687 practitioners.麻醉实践中的用药错误：对687名从业者的调查
Can J Anaesth. 2001 Feb;48(2):139-46. doi: 10.1007/BF03019726.