Lesar T S, Lomaestro B M, Pohl H
Albany Medical Center, NY, USA.
Arch Intern Med. 1997 Jul 28;157(14):1569-76.
Improved understanding of medication prescribing errors should be useful in the design of error prevention strategies.
To report analysis of a 9-year experience with a systematic program of detecting, recording, and evaluating medication-prescribing errors in a teaching hospital.
All medication-prescribing errors with potential for adverse patient outcome detected and averted by staff pharmacists from January 1, 1987, through December 31, 1995, were systematically recorded and analyzed. Errors were evaluated by type of error, medication class involved, prescribing service, potential severity, time of day, and month. Data were analyzed to determine changes in medication-prescribing error frequency and characteristics occurring during the 9-year study period.
A total of 11,186 confirmed medication-prescribing errors with potential for adverse patient consequences were detected and averted during the study period. The annual number of errors detected increased from 522 in the index year 1987 to 2115 in 1995. The rate of errors occurring per order written, per admission, and per patient-day, all increased significantly during the study duration (P < .001). Increased error rates were correlated with the number of admissions (P < .001). Antimicrobials, cardiovascular agents, gastrointestinal agents, and narcotics were the most common medication classes involved in errors. The most common type of errors were dosing errors, prescribing medications to which the patient was allergic, and prescribing inappropriate dosage forms.
The results of this study suggest there may exist a progressively increasing risk of adverse drug events for hospitalized patients. The increased rate of errors is possibly associated with increases in the intensity of medical care and use of drug therapy. Limited changes in the characteristics of prescribing errors occurred, as similar type errors were found to be repeated with increasing frequency. New errors were encountered as new drug therapies were introduced. Health care practitioners and health care systems must incorporate adequate error reduction, prevention, and detection mechanisms into the routine provision of care.
更好地理解药物处方错误对于设计预防策略应是有用的。
报告对一家教学医院9年期间检测、记录和评估药物处方错误的系统项目的分析。
系统记录并分析了1987年1月1日至1995年12月31日期间由药剂师检测并避免的所有可能对患者产生不良后果的药物处方错误。根据错误类型、涉及的药物类别、处方科室、潜在严重程度、一天中的时间和月份对错误进行评估。分析数据以确定9年研究期间药物处方错误频率和特征的变化。
在研究期间共检测并避免了11186例已确认的可能对患者造成不良后果的药物处方错误。检测到的错误年度数量从1987年的522例增加到1995年的2115例。在研究期间，每份医嘱、每次住院和每个患者日的错误发生率均显著增加（P <.001）。错误率的增加与住院人数相关（P <.001）。抗菌药物、心血管药物、胃肠道药物和麻醉药品是错误中最常涉及的药物类别。最常见的错误类型是剂量错误、给患者开具过敏药物以及开具不适当的剂型。
本研究结果表明，住院患者发生药物不良事件的风险可能在逐渐增加。错误率的增加可能与医疗护理强度和药物治疗使用的增加有关。处方错误的特征变化有限，因为发现类似类型的错误频率越来越高。随着新药物疗法的引入，出现了新的错误。医疗从业者和医疗系统必须在日常护理中纳入适当的减少、预防和检测错误的机制。
