Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people
Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people
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DOI：
10.1136/qshc.2009.034231
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发表时间：
2009-10-01
影响因子：
--
通讯作者：
Zermansky, A. G.
中科院分区：
文献类型：
--
作者：
Barber, N. D.;Alldred, D. P.;Zermansky, A. G.
导读：护理院的居民特别容易发生用药错误，我们的目标是确定英国护理院中处方、监测、配药和管理错误的患病率和潜在危害，并确定其原因。方法：在三个地区的有目的的家庭样本中随机抽取居民样本进行前瞻性研究。错误是通过病人访谈，笔记复习，实践观察和检查分配项目来确定的。通过观察和对家庭工作人员、医生和药剂师的理论框架访谈来了解原因。由专家判断评估错误的潜在危害。结果：55个家庭共招募256名居民，平均用药8.0种。178名（69.5%）居民有一个或多个错误。平均每个居民有1.9个错误。处方、监测、给药和调剂错误的平均潜在危害分别为2.6、3.7、2.1和2.0（0 =无危害，10 =死亡）。89个访谈的影响因素包括医生在开处方时难以接近，不了解居民，缺乏家庭信息；家庭工作人员工作量大，缺乏药物培训和药物轮次中断；家庭、诊所和药房之间缺乏团队合作；低效的订购系统；药品记录不准确和语言交流盛行；而且难以填写（和检查）药物管理系统。结论：三分之二的居民暴露于一种或多种药物错误是值得关注的。改善的意愿是存在的，但缺乏全面的责任感。有关各方都必须采取行动。
Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes.Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement.Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff's high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems.Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.