Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran.
Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.
PLoS One. 2024 Aug 22;19(8):e0307753. doi: 10.1371/journal.pone.0307753. eCollection 2024.
The administration of intravenous (IV) medications is a technically complicated and error-prone process. Especially, in the hematopoietic stem cell transplantation (HSCT) setting where toxic drugs are frequently used and patients are in critical immunocompromised conditions, medication errors (ME) can have catastrophic reactions and devastating outcomes such as death. Studies on ME are challenging due to poor methodological approaches and complicated interpretations. Here, we tried to resolve this problem using reliable methods and by defining new denominators, as a crucial part of an epidemiological approach.
This was an observational, cross-sectional study. A total of 525 episodes of IV medication administration were reviewed by a pharmacist using the disguised direct observation method to evaluate the preparation and administration processes of 32 IV medications in three HSCT wards. We reported errors in 3 ratios; 1) Total Opportunities for Error (TOE; the number of errors/sum of all administered doses observed plus omitted medications), 2) Proportional Error Ratio (the number of errors for each drug or situation/total number of detected errors) and, 3) Corrected Total Opportunities for Errors (CTOE; the number of errors/ Sum of Potential Errors (SPE)).
A total of 1,568 errors were observed out of 5,347 total potential errors. TOE was calculated as 2.98 or 298% and CTOE as 29.3%. Most of the errors occurred at the administration step. The most common potential errors were the use of an incorrect volume of the reconstitution solvent during medication preparation and lack of monitoring in the administration stage.
Medication errors frequently occur during the preparation and administration of IV medications in the HSCT setting. Using precise detection methods, denominators, and checklists, we identified the most error-prone steps during this process, for which there is an urgent need to implement effective preventive measures. Our findings can help plan targeted preventive measures and investigate their effectiveness, specifically in HSCT settings.
静脉（IV）给药是一个技术复杂且容易出错的过程。特别是在造血干细胞移植（HSCT）环境中，经常使用毒性药物，且患者处于严重免疫抑制状态，用药错误（ME）可能会产生灾难性反应和毁灭性后果，如死亡。由于方法学方法不完善和解释复杂，对 ME 的研究具有挑战性。在这里，我们尝试使用可靠的方法并通过定义新的分母来解决这个问题，这是流行病学方法的重要组成部分。
这是一项观察性、横断面研究。通过药剂师使用伪装直接观察法，对三个 HSCT 病房的 32 种 IV 药物的准备和给药过程进行了 525 次 IV 药物给药事件的回顾。我们报告了三种比率的错误；1）总机会误差（TOE；错误数量/观察到的所有给药剂量总和加漏服药物），2）比例误差比（每种药物或情况的错误数量/总检测到的错误数量），和 3）校正总机会误差（CTOE；错误数量/潜在错误总数（SPE）。
在总共 5347 个潜在错误中观察到 1568 个错误。TOE 计算为 2.98 或 298%，CTOE 为 29.3%。大多数错误发生在给药步骤。最常见的潜在错误是在药物准备过程中使用不正确的溶剂体积和在给药阶段缺乏监测。
在 HSCT 环境中，IV 药物的准备和给药过程中经常发生用药错误。通过使用精确的检测方法、分母和检查表，我们确定了该过程中最容易出错的步骤，迫切需要实施有效的预防措施。我们的研究结果有助于制定有针对性的预防措施并调查其有效性，特别是在 HSCT 环境中。
