Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database
Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database
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DOI：
10.1111/j.1365-2044.2005.04123.x
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发表时间：
2005-03-01
期刊：
影响因子：
10.7
通讯作者：
Short, TG
中科院分区：
文献类型：
--
作者：
Abeysekera, A;Bergman, IJ;Short, TG
澳大利亚事件监测研究报告了八百九十六起与药品错误有关的事件。注射器和药物配制错误占 452 起（50.4%）事件，其中 169 起（18.9%）涉及更换注射器，其中药物标签正确但给药错误，187 起（20.8%）是由于选择错误的安瓿或药物标签错误造成的。最常见的药物是神经肌肉阻滞剂，其次是阿片类药物。设备误用或故障占另外 234 起 (26.1%) 事件；给药途径不正确 126 起（14.1%）事件；通讯错误事件 35 起（3.9%）。这些事件的结果包括 105 例（11.7%）轻微发病、42 例（4.7%）严重发病、3 例死亡（0.3%）以及 40 例（4.4%）在麻醉下清醒。影响因素包括注意力不集中、仓促、药品标签错误、沟通失败和疲劳。最大限度地减少事件发生的因素包括先前的经验和培训、重新检查能够检测事件的设备和监视器。获得的信息表明需要改进指南以减少用药错误的发生率。需要进一步研究预防策略的有效性。
Eight hundred and ninety-six incidents relating to drug error were reported to the Australian Incident Monitoring Study. Syringe and drug preparation errors accounted for 452 (50.4%) incidents, including 169 (18.9%) involving syringe swaps where the drug was correctly labelled but given in error, and 187 (20.8%) due to selection of the wrong ampoule or drug labelling errors. The drugs most commonly involved were neuromuscular blocking agents, followed by opioids. Equipment misuse or malfunction accounted for a further 234 (26.1%) incidents; incorrect route of administration 126 (14.1%) incidents; and communication error 35 (3.9%) incidents. The outcomes of these events included minor morbidity in 105 (11.7%), major morbidity in 42 (4.7%), death in three (0.3%) and awareness under anaesthesia in 40 (4.4%) incidents. Contributing factors included inattention, haste, drug labelling error, communication failure and fatigue. Factors minimising the events were prior experience and training, rechecking equipment and monitors capable of detecting the incident. The information gained suggests areas where improved guidelines are required to reduce the incidence of drug error. Further research is required into the effectiveness of preventive strategies.