A decade of Australian methotrexate dosing errors
A decade of Australian methotrexate dosing errors
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DOI：
10.5694/mja15.01242
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发表时间：
2016-06-06
影响因子：
11.4
通讯作者：
Buckley, Nicholas A.
中科院分区：
文献类型：
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作者：
Cairns, Rose;Brown, Jared A.;Buckley, Nicholas A.
目的：每日意外服用甲氨蝶呤可能会导致危及生命的毒性。我们调查了向国家死因信息系统 (NCIS)、不良事件通知治疗用品管理数据库 (TGA DAEN) 和澳大利亚毒物信息中心 (PIC) 报告的甲氨蝶呤剂量错误。设计和设置：对 NCIS 中的死因病例 (2000-2014 年) 以及向 TGA DAEN (2004-2014 年) 和澳大利亚毒物信息中心 (PIC) 的报告进行回顾性审查（2004-2015）。如果给药错误是意外的，并且有至少连续 3 天每日给药的证据，则纳入病例。主要结局指标：每年发生的事件、剂量、甲氨蝶呤给药的连续天数、错误原因、临床特征。结果：NCIS 中发现了 22 例与甲氨蝶呤相关的死亡，其中包括 7 例记录了错误每日给药的病例。 DAEN 中列出了 10 例甲氨蝶呤用药错误，其中包括 2 例死亡。澳大利亚 PIC 数据库包含 92 个案例，2014 年至 2015 年期间出现令人担忧的增长。造成这些错误的原因包括患者的误解以及药剂师对剂量包的错误包装。记录的每日剂量的临床效果与之前报道的甲氨蝶呤毒性一致。结论：甲氨蝶呤的剂量错误可能是致命的，并且尽管在过去十年中采取了许多安全措施，但剂量错误仍然会发生。需要实施和评估减少这些可预防危害的进一步策略。最近的建议包括进一步改变包装尺寸、包装上强制性每周剂量标签、改善教育以及在处方和配药软件中添加警报。
Objective: Accidental daily dosing of methotrexate can result in life-threatening toxicity. We investigated methotrexate dosing errors reported to the National Coronial Information System (NCIS), the Therapeutic Goods Administration Database of Adverse Event Notifications (TGA DAEN) and Australian Poisons Information Centres (PICs).Design and setting: A retrospective review of coronial cases in the NCIS (2000-2014), and of reports to the TGA DAEN (2004-2014) and Australian PICs (2004-2015). Cases were included if dosing errors were accidental, with evidence of daily dosing on at least 3 consecutive days.Main outcome measures: Events per year, dose, consecutive days of methotrexate administration, reasons for the error, clinical features.Results: Twenty-two deaths linked with methotrexate were identified in the NCIS, including seven cases in which erroneous daily dosing was documented. Methotrexate medication error was listed in ten cases in the DAEN, including two deaths. Australian PIC databases contained 92 cases, with a worrying increase seen during 2014-2015. Reasons for the errors included patient misunderstanding and incorrect packaging of dosette packs by pharmacists. The recorded clinical effects of daily dosage were consistent with those previously reported for methotrexate toxicity.Conclusion: Dosing errors with methotrexate can be lethal and continue to occur despite a number of safety initiatives in the past decade. Further strategies to reduce these preventable harms need to be implemented and evaluated. Recent suggestions include further changes in packet size, mandatory weekly dosing labelling on packaging, improving education, and including alerts in prescribing and dispensing software.