From the HUS Pharmacy, Hospital Pharmacy of Helsinki University Hospital (HUS).
Clinical Pharmacy Group, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland.
J Patient Saf. 2024 Jun 1;20(4):e29-e39. doi: 10.1097/PTS.0000000000001222. Epub 2024 Apr 1.
Intravenous drug administration has been associated with severe medication errors in hospitals. The present narrative review is based on a systematic literature search, and aimed to describe the recent evolution in research on systemic causes and defenses in intravenous medication errors in hospitals.
This narrative review was based on Reason's theory of systems-based risk management. A systematic literature search covering the period from June 2016 to October 2021 was conducted on Medline (Ovid). We used the search strategy and selection criteria developed for our previous systematic reviews. The included articles were analyzed and compared to our previous reviews.
The updated search found 435 articles. Of the 63 included articles, 16 focused on systemic causes of intravenous medication errors, and 47 on systemic defenses. A high proportion (n = 24, 38%) of the studies were conducted in the United States or Canada. Most of the studies focused on drug administration (n = 21/63, 33%) and preparation (n = 19/63, 30%). Compared to our previous review of error causes, more studies (n = 5/16, 31%) utilized research designs with a prospective risk management approach. Within articles related to systemic defenses, smart infusion pumps remained most widely studied (n = 10/47, 21%), while those related to preparation technologies (n = 7/47, 15%) had increased.
This narrative review demonstrates a growing interest in systems-based risk management for intravenous drug therapy and in introducing new technology, particularly smart infusion pumps and preparation systems, as systemic defenses. When introducing new technologies, prospective assessment and continuous monitoring of emerging safety risks should be conducted.
静脉内给药与医院内严重用药错误有关。本叙述性评论基于系统文献检索，旨在描述近期关于医院内静脉内用药错误的系统性原因和防御措施的研究进展。
本叙述性评论基于基于系统的风险管理的Reason 理论。对 2016 年 6 月至 2021 年 10 月期间的 Medline（Ovid）进行了系统的文献检索。我们使用了为我们之前的系统评价制定的搜索策略和选择标准。对纳入的文章进行了分析，并与我们之前的综述进行了比较。
更新后的搜索发现了 435 篇文章。在纳入的 63 篇文章中，有 16 篇侧重于静脉内用药错误的系统性原因，有 47 篇侧重于系统性防御措施。相当大比例（n = 24，38%）的研究在美国或加拿大进行。大多数研究侧重于药物管理（n = 21/63，33%）和准备（n = 19/63，30%）。与我们之前关于错误原因的综述相比，更多的研究（n = 5/16，31%）采用了具有前瞻性风险管理方法的研究设计。在与系统性防御措施相关的文章中，智能输液泵仍然是研究最广泛的（n = 10/47，21%），而与准备技术相关的文章（n = 7/47，15%）有所增加。
本叙述性评论表明，人们对静脉内药物治疗的基于系统的风险管理以及引入新的技术，特别是智能输液泵和准备系统作为系统性防御措施越来越感兴趣。在引入新技术时，应进行前瞻性评估和对新出现的安全风险进行持续监测。
