Common types of medication errors on long-term psychiatric care units
Common types of medication errors on long-term psychiatric care units
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DOI：
10.1093/intqhc/mzg038
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发表时间：
2003-05-01
影响因子：
2.6
通讯作者：
Yamazumi, S
中科院分区：
文献类型：
--
作者：
Ito, H;Yamazumi, S
目标。这项多中心研究确定了长期精神病护理医院中最常见的药物错误类型。日本。设计和研究参与者。我们要求日本44家精神病院的132个单位在2000年10月1日至11月30日期间引入关于潜在药物不良事件（PADEs）的住院事件报告系统。我们分析了PADE的类型、结果以及患者、工作人员和单位的特征。我们收到44家医院85个单位的221份PADE事件报告。四分之一（24.9%）的事件在到达患者之前被拦截。临床工作人员对患者用药错误的监测频率增加了8.1%。错误给药，即给病人的药物不是为该病人开的药，是最常见的事件类型（35.7%）。Logistic回归分析显示，在注册护士较少的单位，或者在同一单位有两个或两个以上姓名相同（或相似）的患者，错误给药的发生率更高。事件报告者认为错误用药可能比其他类型的用药错误更为严重。在药袋上没有印有病人姓名的单位，错误给药的发生率更高。错误给药是最常见的PADE类型，并且可能导致比其他类型更严重的后果。即使是一个简单的组织质量改进工作，在药袋上印上病人的名字（不仅是在每张处方上，而且在每次给药时），也可以减少病人因用药错误而产生不良后果的风险。
Objective. This multi-center study identified the most frequent types of medication errors in long-term psychiatric care hospitals.Setting. Japan.Design and study participants. We asked 132 units in 44 Japanese psychiatric hospitals to introduce an in-patient incident reporting system on potential adverse drug events (PADEs) for the period 1 October to 30 November 2000. We analyzed types of PADE, outcomes, and characteristics of patients, staff, and units.Results. We received 221 PADE incident reports from 85 units of 44 hospitals. One-quarter (24.9%) of the incidents were intercepted before reaching patients. The frequency of monitoring of the patients by clinical staff in response to medication errors increased by 8.1%. Wrong drug administration, i.e. giving a drug to a patient that was not the drug prescribed for that patient, was the most common type of incident (35.7%). Logistic regression analysis revealed that wrong drug administration occurred more frequently on units with either fewer registered nurses, or two or more patients with the same (or similar) name staying on the same unit. Incident reporters evaluated wrong drug administration as being potentially more serious than the other types of medication error. Wrong drug administration was seen more frequently in units with no patient name printed on medication drug pouches.Conclusions. Wrong drug administration was the most common type of PADE, and may result in more serious consequences than others. Even a simple organizational quality improvement effort, in which printed patients' names are placed on the drug pouch (not only with each prescription but with each drug administration), could reduce risk to patients from adverse outcomes due to medication errors.