急性护理医院中不同年龄组与药物相关的事件：国家患者安全报告数据分析。

Medication-related incidents in acute care hospitals among different age groups: An analysis of national patient safety report data.

机构信息

College of Pharmacy, Chungbuk National University, Cheongju, Republic of Korea.

College of Pharmacy, Seoul National University, Seoul, Republic of Korea.

出版信息

Pharmacoepidemiol Drug Saf. 2024 Jun;33(6):e5819. doi: 10.1002/pds.5819.

DOI:10.1002/pds.5819

PMID:38783417

Abstract

PURPOSE

This study aimed to perform a nationwide analysis of medication errors (MEs) from hospitals using national reporting system data and to compare the ME patterns among different age groups.

METHODS

We analyzed medication-related incidents in acute care hospitals reported to the Korean Patient Safety Reporting and Learning System (KOPS), which is a patient safety reporting system, from July 2016 to December 2020. The stages of the medication use process, type of errors, medication class involved in MEs, and degree of harm were analyzed.

RESULTS

Among a total of 5071 medication-related incidents, 37.7% (1911 cases) were incidents that caused patient harm and 1.2% caused long-term, permanent, and fatal harm. The proportion of medication-related incidents that resulted in harm was the highest among the <1-year-old age group (67 cases, 51.5%), followed by the elderly (≥ 65 years) (828 cases, 40.9%). The cases leading to patient death were most frequently reported in patients aged ≥65 years. Medication-related incidents occurred mainly in the administration stage (2954 cases, 58.3%), and wrong dose was the most frequently reported ME type. The most prevalent medication class occurring in the 20-64-year age group (256 cases, 11.7%) was 'antibacterials for systemic use', whereas 'contrast media' (236 cases, 11.6%) and 'blood substitutes and perfusion solutions' (98 cases, 19.3%) were the most prevalent drug classes in the ≥65- and <20-year-old age groups, respectively.

CONCLUSIONS

It is necessary to establish guidelines for the prevention of medication-related incidents according to the medication use process and patient age group.

摘要

目的

本研究旨在利用国家报告系统数据对医院的用药错误（MEs）进行全国性分析，并比较不同年龄组的 ME 模式。

方法

我们分析了 2016 年 7 月至 2020 年 12 月向韩国患者安全报告和学习系统（KOPS）报告的急性护理医院与用药相关的事件，KOPS 是一个患者安全报告系统。分析了用药过程的各个阶段、错误类型、ME 中涉及的药物类别以及伤害程度。

结果

在总共 5071 起与用药相关的事件中，37.7%（1911 例）是导致患者伤害的事件，1.2%导致长期、永久和致命伤害。<1 岁年龄组（67 例，51.5%）导致与用药相关的事件造成伤害的比例最高，其次是老年人（≥65 岁）（828 例，40.9%）。导致患者死亡的病例主要报告发生在≥65 岁的患者中。与用药相关的事件主要发生在给药阶段（2954 例，58.3%），剂量错误是最常见的 ME 类型。20-64 岁年龄组最常见的药物类别是“全身用抗菌药”（256 例，11.7%），而≥65 岁和<20 岁年龄组最常见的药物类别分别是“造影剂”（236 例，11.6%）和“血液替代品和灌注溶液”（98 例，19.3%）。