Buehler J W, Smith L F, Wallace E M, Heath C W, Kusiak R, Herndon J L
N Engl J Med. 1985 Jul 25;313(4):211-6. doi: 10.1056/NEJM198507253130402.
During a nine-month period, July 1980 through March 1981, the mortality rate for patients on the cardiology ward of a children's hospital was 43.1 deaths per 10,000 patient-days, as compared with 11.0 deaths per 10,000 patient-days during the preceding 54 months. Twenty-five (76 per cent) of 33 infant deaths during this nine-month period occurred between midnight and 6:00 a.m., as compared with 1 of 10 infant deaths during a separate 27-month period (P less than 0.001). Although nearly all deaths occurred in patients with serious congenital heart disease, epidemic-period deaths were more likely to have an unexpected timing and a clinical pattern consistent with digoxin toxicity. In four patients, forensic and clinical digoxin measurements suggested that an intravenous overdose of digoxin had been administered shortly before death. Although a review of nursing schedules revealed a strong association (relative risk, 64.6) between infant deaths and the duty times of a particular nurse, the cause of the epidemic remains unclear. The study led to suggestions that the hospital strengthen central control over procedures for dispensing medicines and implement a system for monitoring the occurrence of deaths by time and place within the hospital.
在1980年7月至1981年3月这九个月期间，一家儿童医院心脏病房患者的死亡率为每10000个患者日43.1例死亡，而在前54个月期间该死亡率为每10000个患者日11.0例死亡。在这九个月期间33例婴儿死亡中有25例（76%）发生在午夜至凌晨6点之间，而在另一个27个月期间10例婴儿死亡中仅有1例发生在此时间段（P小于0.001）。尽管几乎所有死亡都发生在患有严重先天性心脏病的患者中，但流行期间的死亡更可能具有意外的时间点以及与地高辛中毒相符的临床症状。在4例患者中，法医和临床对地高辛的检测表明在死亡前不久曾静脉注射过量地高辛。尽管对护理排班的审查显示婴儿死亡与一名特定护士的值班时间之间存在密切关联（相对风险为64.6），但此次流行的原因仍不清楚。该研究提出建议，医院应加强对药品配给程序的集中控制，并实施一套对医院内按时间和地点发生的死亡情况进行监测的系统。
