Aldayyen Ali M, Alwabari Mohammad A, Alhaddad Fatimah, Alhumaid Murtadha A, Alsuwailem Naseem, Alanzi Amal, Alalwan Abdullah A, Alfayez Osamah, Alwafai Sana, Aldosari Saad A, Ahmed Nehad J, Almalki Ziyad, Alamer Ahmad
Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Alahsa 31982, Saudi Arabia.
Department of Pharmacy, Prince Sultan Hospital, Nairyah 37641, Saudi Arabia.
Saudi Pharm J. 2023 Apr;31(4):569-577. doi: 10.1016/j.jsps.2023.02.009. Epub 2023 Mar 4.
Medication errors (MEs) are a huge burden on any healthcare system and have been associated with significant morbidity and mortality. The medical literature reported heavily on MEs but lacked focus on analyzing high-risk medications such as antimicrobials.
This was a retrospective analysis of the MEs database reported by the eastern region's medical centers in Saudi Arabia from January 1, 2019 to December 31, 2019. We used descriptive analysis to identify most common antimicrobials with errors, the stage of antimicrobial errors, type of the errors, contributing factors to the errors, and categories of errors based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) classification of errors.
A total of 1422 (22.1%) antimicrobial errors were identified out of 6412 MEs. Amoxicillin/Clavulanate (18%) was the most common antimicrobial reported in the database. Most errors occurred in the prescribing phase (87.6%) and included mainly incorrect doses (32.1%) and duplicate therapy (20.5%). In addition, most errors were identified as category B (72.5%). Finally, inexperienced personnel (57.9%) was the most cited contributing factor.
This study revealed that antimicrobial errors occur primarily during prescription and that policy gaps and inexperienced staff were contributory factors. To improve, the focus should shift to physician education, clear dosing guidelines, efficient workload management, and implementing antimicrobial stewardship programs to promote appropriate antimicrobial use.
用药错误对任何医疗系统来说都是巨大的负担,并且与显著的发病率和死亡率相关。医学文献大量报道了用药错误,但缺乏对诸如抗菌药物等高风险药物的分析重点。
这是一项对沙特阿拉伯东部地区医疗中心在2019年1月1日至2019年12月31日期间报告的用药错误数据库进行的回顾性分析。我们使用描述性分析来确定最常出现错误的抗菌药物、抗菌药物错误的阶段、错误类型、错误的促成因素以及根据国家用药错误报告和预防协调委员会(NCC-MERP)错误分类的错误类别。
在6412例用药错误中,共识别出1422例(22.1%)抗菌药物错误。数据库中报告的最常见抗菌药物是阿莫西林/克拉维酸(18%)。大多数错误发生在处方阶段(87.6%),主要包括剂量不正确(32.1%)和重复治疗(20.5%)。此外,大多数错误被确定为B类(72.5%)。最后,经验不足的人员(57.9%)是最常被提及的促成因素。
本研究表明,抗菌药物错误主要发生在处方过程中,政策漏洞和工作人员经验不足是促成因素。为了改进,应将重点转向医生教育、明确的给药指南、有效的工作量管理以及实施抗菌药物管理计划以促进抗菌药物的合理使用。