南非麻醉师给药错误：一项横断面描述性研究。
Drug administration errors among anaesthesia providers in South Africa: a cross-sectional descriptive study.
机构信息
Department Anaesthesiology and Critical Care, University of Stellenbosch, Parow, Cape Town, 7500, South Africa.
出版信息
BMC Anesthesiol. 2024 Aug 3;24(1):270. doi: 10.1186/s12871-024-02657-9.
BACKGROUND
Drug administration errors (DAEs) in anaesthesia are common, the aetiology multifactorial and though mostly inconsequential, some lead to substantial harm. The extend of DAEs remain poorly quantified and effective implementation of prevention strategies sparse.
METHOD
A cross-sectional descriptive study was conducted using a peer-reviewed survey questionnaire, circulated to 2217 anaesthetists via a national communication platform. The aim was to determine the self-reported frequency, nature, contributing factors and reporting patterns of DAEs among anaesthesia providers in South Africa.
RESULTS
Our cohort had a response rate was 18.9%, with 420 individuals populating the questionnaire. 92.5% of surveyed participants have made a DAE and 89.2% a near-miss. Incorrect route of administration, potentially resulting in serious harm, accounted for 8.2% (n = 23/N = 279) of these errors. DAEs mostly reported in cases involving adult patients (80.5%, n = 243/N = 302), receiving a general anaesthetic (71.8%, n = 216/N = 301), where the drug-administrator prepared the drugs themselves (78.7%, n = 218/N = 277), during normal daytime hours (69.9%, n = 202/N = 289) with good lightning conditions (93.0%, n = 265/N = 285). 26% (n = 80/N = 305) of DAEs involved ampoule misidentification, whilst syringe identification error reported in 51.6% (n = 150/N = 291) of cases. DAEs are often not reported (40.3%, n = 114/N = 283), with knowledge of correct reporting procedures lacking. 70.5% (n = 198/N = 281) of DAEs were never discussed with the patient.
CONCLUSIONS
DAEs in anaesthesia remain prevalent. Known error traps continue to drive these incidents. Implementation of system based preventative strategies are paramount to guard against human error. Efforts should be made to encourage scrupulous reporting and training of anaesthesia providers, with the aim of rendering them proficient and resilient to handle these events.
背景
麻醉中的用药错误（DAE）很常见，病因多因素，但大多数没有后果，有些则会导致严重伤害。DAE 的程度仍未得到充分量化，预防策略的有效实施也很匮乏。
方法
本研究采用了一项横断面描述性研究，使用同行评审的调查问卷，通过一个国家通信平台向 2217 名麻醉师分发问卷。目的是确定南非麻醉师报告的 DAE 的频率、性质、促成因素和报告模式。
结果
我们的队列应答率为 18.9%，共有 420 人填写了问卷。92.5%的被调查参与者曾发生过 DAE，89.2%发生过接近差错。给药途径错误，可能导致严重伤害，占这些错误的 8.2%（n=23/N=279）。DAE 主要报告在涉及成年患者的病例中（80.5%，n=243/N=302），接受全身麻醉（71.8%，n=216/N=301），药物使用者自己准备药物（78.7%，n=218/N=277），在正常白天时间（69.9%，n=202/N=289），照明条件良好（93.0%，n=265/N=285）。26%（n=80/N=305）的 DAE 涉及安瓿错误识别，而注射器识别错误在 51.6%（n=150/N=291）的病例中报告。DAE 通常未报告（40.3%，n=114/N=283），缺乏正确报告程序的知识。70.5%（n=198/N=281）的 DAE 从未与患者讨论过。
结论
麻醉中的 DAE 仍然很普遍。已知的错误陷阱继续导致这些事件。实施基于系统的预防策略对于防止人为错误至关重要。应努力鼓励严格报告和培训麻醉师，使他们熟练且有能力处理这些事件。
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