Medication errors in prescription and administration in critically ill patients.
critical illness
intensive care unit
medication errors
nursing
patient safety
Journal
Journal of advanced nursing
ISSN: 1365-2648
Titre abrégé: J Adv Nurs
Pays: England
ID NLM: 7609811
Informations de publication
Date de publication:
May 2020
May 2020
Historique:
received:
23
08
2019
revised:
16
12
2019
accepted:
29
01
2020
pubmed:
8
2
2020
medline:
2
2
2021
entrez:
8
2
2020
Statut:
ppublish
Résumé
To determine the prevalence and magnitude of medication errors and their association with patients' sociodemographic and clinical characteristics and nurses' work conditions. An observational, analytical, cross-sectional and ambispective study was conducted in critically ill adult patients. Data concerning prescription errors were collected retrospectively from medical records and administration errors were identified through direct observation of nurses during drug administration. Those data were collected between April and July 2015. A total of 650 prescription errors were identified for 961 drugs in 90 patients (mean error 7[SD 4.1] per patient) and prevalence of 47.1% (95% CI 44-50). The most frequent error was omission of the prescribed medication. Intensive care unit stay was a risk factor associated with omission error (OR 2.14; 1.46-3.14: p < .01). A total of 294 administration errors were identified for 249 drugs in 52 patients (mean error 6 [SD 6.7] per patient) and prevalence of 73.5% (95% CI 68-79). The most frequent error was interruption during drug administration. Admission to the intensive care unit (OR 0.37; 0.21-0.66: p < .01), nurses' morning shift (OR 2.15; 1.10-4.18: p = .02) and workload perception (OR 3.64; 2.09-6.35: p < .01) were risk factors associated with interruption. Medication errors in prescription and administration were frequent. Timely detection of errors and promotion of a medication safety culture are necessary to reduce them and ensure the quality of care in critically ill patients. Medication errors occur frequently in the intensive care unit but are not always identified. Due to the vulnerability of seriously ill patients and the specialized care they require, an error can result in serious adverse events. The study shows that medication errors in prescription and administration are recurrent but preventable. These findings contribute to promote awareness in the proper use of medications and guarantee the quality of nursing care. 目的: 确定用药失误的发生率、程度及其与患者社会人口学、临床特征以及护士工作条件之间的关系。 设计: 对成年危重患者进行观察性、分析性、横向和双向性研究。 方法: 从病历中回顾性收集处方错误相关数据,并通过对护士在用药期间的直接观察,发现用药失误。此类数据于2015年4月至7月期间收集。 结果: 在90例患者使用的961种药物中共发现有650个处方错误(平均错误率7【SD 4.1】),发生率为47.1%(95%CI 44-50)。最为常见的一类错误是漏开处方药。重症监护病房住院时间是导致出现漏开失误的一大相关风险因素(OR2.14;1.46-3.14:p< .01)。52例患者使用的249种药物中共发现有294个用药失误(平均失误率为6【SD 6.7】),发生率为73.5%(95%CI 68-79)。最为常见的一类失误是用药期间出现中断。入住重症监护病房(OR0.37;0.21-0.66:p< .01)、护士早班交接(OR2.15;1.10-4.18:p= .02)以及工作负荷感知(OR3.64;2.09-6.35:p< .01)为导致用药中断的相关风险因素。 结论: 处方用药错误频发。及时发现错误并倡导药物安全知识,对减少错误、保证危重患者护理质量具有重要意义。 影响: 在重症监护病房,药物错误经常发生,但并非总是得以发现。由于重病患者身体脆弱,且需特殊护理,此类错误可能导致严重的不良事件。研究表明,处方用药错误虽频频发生,但可予以预防。此等发现有助于提高人们对正确使用药物的认识,保证护理质量。.
Autres résumés
Type: Publisher
(chi)
目的: 确定用药失误的发生率、程度及其与患者社会人口学、临床特征以及护士工作条件之间的关系。 设计: 对成年危重患者进行观察性、分析性、横向和双向性研究。 方法: 从病历中回顾性收集处方错误相关数据,并通过对护士在用药期间的直接观察,发现用药失误。此类数据于2015年4月至7月期间收集。 结果: 在90例患者使用的961种药物中共发现有650个处方错误(平均错误率7【SD 4.1】),发生率为47.1%(95%CI 44-50)。最为常见的一类错误是漏开处方药。重症监护病房住院时间是导致出现漏开失误的一大相关风险因素(OR2.14;1.46-3.14:p< .01)。52例患者使用的249种药物中共发现有294个用药失误(平均失误率为6【SD 6.7】),发生率为73.5%(95%CI 68-79)。最为常见的一类失误是用药期间出现中断。入住重症监护病房(OR0.37;0.21-0.66:p< .01)、护士早班交接(OR2.15;1.10-4.18:p= .02)以及工作负荷感知(OR3.64;2.09-6.35:p< .01)为导致用药中断的相关风险因素。 结论: 处方用药错误频发。及时发现错误并倡导药物安全知识,对减少错误、保证危重患者护理质量具有重要意义。 影响: 在重症监护病房,药物错误经常发生,但并非总是得以发现。由于重病患者身体脆弱,且需特殊护理,此类错误可能导致严重的不良事件。研究表明,处方用药错误虽频频发生,但可予以预防。此等发现有助于提高人们对正确使用药物的认识,保证护理质量。.
Substances chimiques
Prescription Drugs
0
Types de publication
Journal Article
Observational Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
1192-1200Informations de copyright
© 2020 John Wiley & Sons Ltd.
Références
Armitage, G., & Knapman, H. (2003). Adverse events in drug administration: A literature review. Journal of Nursing Management, https://doi.org/10.1046/j.1365-2834.2003.00359.x
Berdot, S., Roudot, M., Schramm, C., Katsahian, S., Durieux, P., & Sabatier, B. (2016). Interventions to reduce nurses' medication administration errors in inpatient settings: A systematic review and meta-analysis. International Journal of Nursing Studies, 53, 342-350. https://doi.org/10.1016/j.ijnurstu.2015.08.012
Bowdle, T. (2003). Drug administration errors from the ASA Closed Claims Project. ASA Newsletter, 67(6), 11-13.
Carayon, P., Wetterneck, T. B., Cartmill, R., Blosky, M. A., Brown, R., Kim, R., … Walker, J. (2014). Characterising the complexity of medication safety using a human factors approach: An observational study in two intensive care units. BMJ Quality and Safety, https://doi.org/10.1136/bmjqs-2013-001828
Catchpole, K. (2013). Spreading human factors expertise in healthcare: Untangling the knots in people and systems. BMJ Quality and Safety, https://doi.org/10.1136/bmjqs-2013-002036
Cousins, D. D., & Heath, W. M. (2008). The national coordinating council for medication error reporting and prevention: Promoting patient safety and quality through innovation and leadership. Joint Commission Journal on Quality and Patient Safety, 34(12), 700-702. https://doi.org/10.1016/S1553-7250(08)34091-4
De Araújo, B. C., De Melo, R. C., De Bortoli, M. C., De Alcântara Bonfim, J. R., & Toma, T. S. (2019). How to prevent or reduce prescribing errors: An evidence brief for policy. Frontiers in Pharmacology, 10, 439. https://doi.org/10.3389/fphar.2019.00439.
Di Giulio, A. M. (2018). Farmacologia generale e speciale: Per le lauree sanitarie. Padova, Italy: PICCIN Nuova Libraria.
Di Simone, E., Tartaglini, D., Fiorini, S., Petriglieri, S., Plocco, C., & Di Muzio, M. (2016). Medication errors in intensive care units: Nurses’ training needs. Emergency Nurse, 24(4), 24-29. https://doi.org/10.7748/en.2016.11577
Donati, D., Tartaglini, D., & Di Muzio, M. (2015). L'errore nella somministrazione di terapia farmacologica endovenosa nelle Unità di Terapia Intensiva: Stato dell'arte e strategie. Scenario, 32(2), 20-27.
Elganzouri, E. S., Standish, C. A., & Androwich, I. (2009). Medication administration time study (mats): Nursing staff performance of medication administration. Journal of Nursing Administration, https://doi.org/10.1097/NNA.0b013e3181a23d6d
Frith, K. H. (2013). Medication errors in the intensive care unit: Literature review using the seips model. AACN Advanced Critical Care, 24(4), 389-404. https://doi.org/10.1097/NCI.0b013e3182a8b516
George, E. L., Henneman, E. A., & Tasota, F. J. (2010). Nursing implications for prevention of adverse drug events in the intensive care unit. Critical Care Medicine, 38, S136-S144. https://doi.org/10.1097/CCM.0b013e3181de0b23
Grünewald, R. A., & Mack, C. J. (2001). Medical errors. Different formulations of drugs often look confusingly similar. BMJ (Clinical Research Ed.), 322, 1423-1423.
Gurses, A. P., Ozok, A. A., & Pronovost, P. J. (2012). Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Quality and Safety, 21, 347-351. https://doi.org/10.1136/bmjqs-2011-000421
Henneman, E. A. (2017). Recognizing the ordinary as extraordinary: Insight into the “Way We Work”to improve patient safety outcomes. American Journal of Critical Care, 26(4), 272-277. https://doi.org/10.4037/ajcc2017812
Kendall-Gallagher, D., & Blegen, M. A. (2009). Competence and certification of registered nurses and safety of patients in intensive care units. American Journal of Critical Care, 18(2), 106-113. https://doi.org/10.4037/ajcc2009487
Kohn, L., Corrigan, J., & Donaldson, M. S. (1999). Committee on quality of health care in America. To err is human: Building a safer health system. Washington, DC: National Academy Press.
Krähenbühl-Melcher, A., Schlienger, R., Lampert, M., Haschke, M., Drewe, J., & Krähenbühl, S. (2007). Drug-related problems in hospitals: A review of the recent literature. Drug Safety, 30(5), 379-407. https://doi.org/10.2165/00002018-200730050-00003
Kuo, G. M., Phillips, R. L., Graham, D., & Hickner, J. M. (2008). Medication errors reported by US family physicians and their office staff. Quality and Safety in Health Care, 17(4), 286-290. https://doi.org/10.1136/qshc.2007.024869
Lacasa, C., & Ayestarán, A.. (2012). Estudio Multicéntrico español para la Prevención de Errores de Medicación. Resultados de cuatro años (2007-2011). Farmacia Hospitalaria, 36(5), 356-367. https://doi.org/10.1016/j.farma.2011.10.002
Mack, C. J., Kuc, S., & Grünewald, R. A. (2000). Errors in prescribing, dispensing and administration of carbamazepine: A case report and analysis. Pharmaceutical Journal, 265(7123), 756-758.
Merino, P., Martín, M. C., Alonso, A., Gutiérrez, I., Álvarez, J., & Becerril, F. (2013). Medication errors in Spanish intensive care units. Medicina Intensiva (English Edition), 37(6), 391-399. https://doi.org/10.1016/j.medine.2012.11.004
Miasso, A. I., De Oliveira, R. C., De Camargo Silva, A. E. B., De Lyra, D. P., Gimenes, F. R. E., Fakih, F. T., & De Bortoli Cassiani, S. H. (2009). Prescription errors in Brazilian hospitals: A multi-centre exploratory survey. Cadernos De Saude Publica, 25(2), 313-320. https://doi.org/10.1590/S0102-311X2009000200009
Moyen, E., Camiré, E., & Stelfox, H. T. (2008). Clinical review: Medication errors in critical care. Critical Care, 12(2), 208. https://doi.org/10.1186/cc6813
Muroi, M., Shen, J. J., & Angosta, A. (2017). Association of medication errors with drug classifications, clinical units and consequence of errors: Are they related? Applied Nursing Research, 33, 180-185. https://doi.org/10.1016/j.apnr.2016.12.002
Nicole Salazar, L., Marcela Jirón, A., Leslie Escobar, O., Tobar, E., & Romero, C. (2011). Errores de medicación en pacientes críticos adultos de un hospital universitario: Estudio prospectivo y aleatorio. Revista Médica De Chile, 139(11), 1458-1464. https://doi.org/10.4067/S0034-98872011001100010
Otero López, M. J., Martín Muñoz, M. R., Castaño Rodríguez, B., Palomo Cobos, L., Cajaraville Ordoñana, G., Codina Jané, C., … Grupo de Trabajo, M. S. S. A. (2008). Assessment of safety practices for medication-use systems in Spanish hospitals (2007). Medicina Clinica, 131(Suppl 3), 39-47.
PSNet Patient Safety Network (2019). Medication Errors and Adverse Drug Events | AHRQ Patient Safety Network. Retrieved from https://psnet.ahrq.gov/primers/primer/23/Medication-Errors-and-Adverse-Drug-Events, August 22, 2019.
Rhodes, A., Moreno, R. P., Azoulay, E., Capuzzo, M., Chiche, J. D., Eddleston, J., … Valentin, A. (2012). Prospectively defined indicators to improve the safety and quality of care for critically ill patients: A report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM). Intensive Care Medicine, 38(4), 598-605. https://doi.org/10.1007/s00134-011-2462-3
Ridley, S. A., Booth, S. A., Thompson, C. M., Clayton, T., Eddleston, J., Mackenzie, S., … Wright, D. (2004). Prescription errors in UK critical care units. Anaesthesia, 59(12), 1193-1200. https://doi.org/10.1111/j.1365-2044.2004.03969.x
Romero, C. M., Salazar, N., Rojas, L., Escobar, L., Griñén, H., Berasaín, M. A., … Jirón, M. (2013). Effects of the implementation of a preventive interventions program on the reduction of medication errors in critically ill adult patients. Journal of Critical Care, 28(4), 451-460. https://doi.org/10.1016/j.jcrc.2012.11.011
Rovinski-Wagner, C., & Mills, P. D. (2018). Patient safety. In Introduction to quality and safety education for nurses: Core competencies for nursing leadership and management (2nd ed., pp. 339-374), New York, NY: Springer Publishing Company. https://doi.org/10.1891/9780826123855.0012
Rozenblum, R., Rodriguez-Monguio, R., Volk, L. A., Forsythe, K. J., Myers, S., McGurrin, M., … Seoane-Vazquez, E. (2019). Using a machine learning system to identify and prevent medication prescribing errors: A clinical and cost analysis evaluation. The Joint Commission Journal on Quality and Patient Safety, 46(1), 3-10. https://doi.org/10.1016/j.jcjq.2019.09.008
Sarfati, L., Ranchon, F., Vantard, N., Schwiertz, V., Larbre, V., Parat, S., … Rioufol, C. (2019). Human-simulation-based learning to prevent medication error: A systematic review. Journal of Evaluation in Clinical Practice, 25, 11-20. https://doi.org/10.1111/jep.12883
Shekelle, P. G., Wachter, R. M., Pronovost, P. J., Schoelles, K., McDonald, K. M., Dy, S. M., Winters, B. D. (2013). Making health care safer II: an updated critical analysis of the evidence for patient safety practices. Evidence Report/Technology Assessment.
Valentin, A., Capuzzo, M., Guidet, B., Moreno, R., Metnitz, B., Bauer, P., & Metnitz, P. (2009). Errors in administration of parenteral drugs in intensive care units: Multinational prospective study. BMJ (Online), 338(mar12 1), b814. https://doi.org/10.1136/bmj.b814
World Health Organization (2009). The conceptual framework for the international classification for patient safety version 1.1 Final Technical. Report. Available at http://www.who.int/patientsafety/
World Health Organization (2010). A brief synopsis on patient safety. Europe: WHO.
World Health Organization (2017a). Medication without harm WHO global patient safety challenge. Retrieved from http://apps.who.int/bookorders.
World Health Organization (2017b). WHO launches global effort to halve medication-related errors in 5 years. Retrieved from https://www.who.int/news-room/detail/29-03-2017-who-launches-global-effort-to-halve-medication-related-errors-in-5-years, August 22, 2019.