PHE3ID, Centre International de Recherche en Infectiologie, Service d'Anesthésie Réanimation - Médecine Intensive, Institut National de la Santé et de la Recherche Médicale U1111, CNRS Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France.
Service de pharmacie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France.
J Med Syst. 2024 Aug 22;48(1):78. doi: 10.1007/s10916-024-02099-3.
The integration of Computerized Provider Order Entry (CPOE) systems in hospitals has been instrumental in reducing medication errors and enhancing patient safety. This study examines the implications of a software oversight in a CPOE system : Metoclopramide had a concentrated formulation (100 mg) delisted (and then not manufactured) in 2014 due to safety concerns. Despite this, the CPOE system continued to accept prescriptions for this formulation because it was not removed from the medication library by the pharmacist. The objective of our study was to describe this specific prescription error related to an outdated the medication library of the CPOE. We analyzed all metoclopramide prescriptions from 2014, to 2023. Our findings showed that errors involving 100 mg or more dosages were relatively rare, at 2.98 per 1000 prescriptions (34 errors in 11,372 prescriptions). Notably, 47.1% of these errors occurred during on-call shifts, and 68% of these errors led to actual administration. These errors correlated with periods of higher nurse workload. The findings advocate for the integration of dedicated pharmacists into ICU teams to minimize medication errors and enhance patient outcomes, and a proactive medication management in healthcare.
医院中计算机化医嘱录入（CPOE）系统的整合对于减少用药错误和提高患者安全性起到了重要作用。本研究探讨了 CPOE 系统中的软件疏忽的影响：由于安全问题，胃复安的浓缩配方（100mg）于 2014 年被撤市（此后不再生产）。尽管如此，由于药剂师没有从药物库中删除该配方，CPOE 系统仍继续接受该配方的处方。我们研究的目的是描述与 CPOE 的过时药物库相关的特定处方错误。我们分析了 2014 年至 2023 年期间所有的胃复安处方。我们的研究结果表明，涉及 100mg 或更高剂量的错误相对较少，每 1000 份处方中有 2.98 份（11372 份处方中有 34 份错误）。值得注意的是，这些错误中有 47.1%发生在值班期间，其中 68%导致了实际给药。这些错误与护士工作量较高的时期相关。研究结果提倡将专门的药剂师纳入 ICU 团队，以最大限度地减少用药错误并改善患者预后，并在医疗保健中进行积极主动的药物管理。
