一系列干预措施对新生儿及儿科重症监护病房肠外药物配制错误范围的影响

Impact of a Bundle of Interventions on the Spectrum of Parenteral Drug Preparation Errors in a Neonatal and Pediatric Intensive Care Unit.

作者信息

von Hobe Sabine, Schoberer Mark, Orlikowsky Thorsten, Müller Julia, Kusch Nina, Eisert Albrecht

机构信息

Hospital Pharmacy, RWTH Aachen University Hospital, 52074 Aachen, Germany.

Section of Neonatology, Department of Pediatric and Adolescent Medicine, RWTH Aachen University Hospital, 52074 Aachen, Germany.

出版信息

J Clin Med. 2024 Oct 11;13(20):6053. doi: 10.3390/jcm13206053.

Abstract

: This study aimed to evaluate the impact of a bundle of interventions on the error rates in preparing parenteral medications in a neonatal and pediatric intensive care unit (NICU/PICU). : We conducted a prospective interventional study in a NICU/PICU in a tertiary university hospital as a follow-up to a prior study in the same setting. A clinical pharmacist and a pharmacy technician (PT) analyzed the workflow of drug preparation on the ward, identified high-alert medications, and defined a bundle of five interventions, which include the following: Drug Labeling: 1. EN ISO-DIVI labeling; Training: 2. Standardized preparation process on the ward; 3. eLearning Program; 4. Expert Consultations; and Location of Preparation: 5. Transfer of the preparation of high-alert medications and standardized preparations to the central pharmacy. After implementing the bundle of interventions, we observed the preparation process on the ward to evaluate if the implementation of the interventions had an impact on the quality of the drug preparation. : We observed 262 preparations in the NICU/PICU. Each single step of the preparation process was defined as an error opportunity. We defined seven error categories with an overall error opportunity of 1413. In total, we observed 11 errors (0.78%). The reduction in the overall error rate from 1.32% in the former study to 0.78% per preparation opportunity demonstrated that the implemented interventions were effective in enhancing medication safety. : This study provides evidence that a bundle of interventions, including standardizing drug labeling, enhancing training, and centralizing the preparation of high-alert medications, can reduce medication errors in NICU/PICU settings.

摘要

本研究旨在评估一系列干预措施对新生儿及儿科重症监护病房(NICU/PICU)肠外用药配制错误率的影响。我们在一所三级大学医院的NICU/PICU进行了一项前瞻性干预研究,作为同一环境下先前一项研究的后续研究。一名临床药师和一名药房技术员(PT)分析了病房内药物配制的工作流程,确定了高警示药物,并定义了一系列五项干预措施,具体如下:药物标签:1. EN ISO-DIVI标签;培训:2. 病房内标准化配制流程;3. 电子学习项目;4. 专家咨询;以及配制地点:5. 将高警示药物和标准化制剂的配制转移至中心药房。实施这些干预措施后,我们观察了病房内的配制过程,以评估干预措施的实施是否对药物配制质量产生影响。我们在NICU/PICU观察了262次配制过程。配制过程的每一个步骤都被定义为一个错误机会。我们定义了七个错误类别,总错误机会为1413次。总共,我们观察到11次错误(0.78%)。总体错误率从前一项研究中的1.32%降至每次配制机会的0.78%,这表明实施的干预措施在提高用药安全性方面是有效的。本研究提供了证据,表明一系列干预措施——包括标准化药物标签、加强培训以及集中高警示药物的配制——可以减少NICU/PICU环境中的用药错误。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/aa27/11509000/36bbbcc36511/jcm-13-06053-g001.jpg

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