Schneider M P, Cotting J, Pannatier A
Pharmacy Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
Pharm World Sci. 1998 Aug;20(4):178-82. doi: 10.1023/a:1012087727393.
The objectives of this study were to determine the frequency and the types of errors which occur regarding the preparation and the administration of medication and to identify the main causes of these errors in a pediatric intensive care unit (PICU) at the University Hospital in Lausanne (Switzerland). In this prospective study, based on the observation of nurses' activities, the data were collected over a period of 10 weeks. The error classification was based on the American Society of Hospital Pharmacy (ASHP) definitions. The frequency of errors was calculated as the sum of all noted errors divided by the total administered drugs, plus the sum of all omitted drugs, multiplied by 100. The sum of all given doses plus all omitted doses gives the 'total opportunity for errors'. This total was 275 and the total frequency of errors was 26.9%. The most frequent errors were wrong-time errors (32.4%), wrong-administration-technique errors (32.4%) and preparation errors (23.0%). In relation with other studies conducted under comparable conditions, a lesser number of omissions and wrong-time errors were observed. On the contrary, administration-technique and dose-preparation errors were more frequent at our hospital. A program of systematic assistance and survey by professional pharmacists could improve the quality of the preparation and administration of medication in the PICU.
本研究的目的是确定在瑞士洛桑大学医院的儿科重症监护病房（PICU）中，药物制备和给药过程中出现错误的频率及类型，并找出这些错误的主要原因。在这项前瞻性研究中，基于对护士活动的观察，在10周的时间内收集数据。错误分类基于美国医院药师协会（ASHP）的定义。错误频率的计算方法是，将所有记录的错误总和除以给药总数，再加上所有漏给药的总和，然后乘以100。所有已给药剂量与所有漏给药剂量之和即为“错误总机会数”。这个总数为275，错误总频率为26.9%。最常见的错误是给药时间错误（32.4%）、给药技术错误（32.4%）和制备错误（23.0%）。与在类似条件下进行的其他研究相比，观察到的漏给药和给药时间错误数量较少。相反，在我们医院，给药技术和剂量制备错误更为常见。由专业药剂师进行系统协助和调查的项目可以提高PICU中药物制备和给药的质量。
