儿科药物事件报告:对在审计中发现的药物错误的多中心比较研究,由工作人员检测并报告给事件系统
Ling Li1, Tim Badgery-Parker2, Alison Merchant2
1Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia ling.li@mq.edu.au.
BMJ quality & safety
|April 15, 2024
概括
事件报告系统显著低于儿童医院的药物错误和伤害. 改进的检测和自动监测对于提高儿童患者安全和准确的药物错误报告至关重要.
科学领域:
- 儿科患者的安全性
- 药物错误分析 药物错误分析
- 改善医疗保健质量 改善医疗保健质量
背景情况:
- 药物错误对儿科患者构成重大风险.
- 事件报告系统是识别和解决这些错误的主要方法.
- 儿科环境中事件报告的准确性和完整性需要进行彻底的调查.
研究的目的:
- 通过审计和直接观察发现的药物错误与通过澳大利亚儿科医院的事件报告系统报告的错误进行比较.
- 调查检测到的药物错误类型和严重性的差异与医疗人员报告的差异.
- 评估当前事件报告机制在捕获药物错误和相关患者伤害的真实发生率方面的有效性.
主要方法:
- 这项比较研究于2016年至2020年在澳大利亚的两家三级儿科医院进行.
- 通过药物表审计发现的处方错误 (7785名患者记录).
- 通过直接观察发现的药物管理错误 (5137剂给1530名患者),随后与事件报告进行匹配.
主要成果:
- 报告的处方错误很少 (3.2/1000) 和可能严重的处方错误 (11.2/1000).
- 在与实际患者伤害相关的错误中,只有17.5%被检测到,10.0%报告.
- 通过事件系统,没有报告药物管理错误,包括那些对患者有害的错误.
结论:
- 事件报告数据并不准确地反映了儿科医院中药物错误和伤害的普遍性.
- 药物错误的不足检测是导致报告率低的一个主要因素.
- 建议使用自动化实时监控系统,以改善电子健康记录时代的药物安全监测.
相关概念视频
01:19Pharmacovigilance
830
Post-marketing surveillance is a critical component of pharmaceutical regulation, often uncovering unanticipated adverse drug reactions (ADRs) once a drug is widely used over an extended period.
This process, termed pharmacovigilance, aims to detect, evaluate, and minimize harmful effects related to medication use. The data collection for pharmacovigilance depends on spontaneous reporting systems, where healthcare professionals or patients voluntarily report suspected ADRs.
In some cases, there...
This process, termed pharmacovigilance, aims to detect, evaluate, and minimize harmful effects related to medication use. The data collection for pharmacovigilance depends on spontaneous reporting systems, where healthcare professionals or patients voluntarily report suspected ADRs.
In some cases, there...
830
01:21Types of Reports II: Incident or Occurrence Report
827
An Incident or Occurrence Report in a healthcare setting is a crucial document used to record any unexpected occurrence that may or may not have affected a patient, employee, or visitor. Such reports are critical to improving patient safety and include all details leading up to and including the event.
Purposes:
In the healthcare industry, reports play a crucial role in documenting incidents within an agency. The primary objective of these reports is to ensure patient safety, uphold the...
Purposes:
In the healthcare industry, reports play a crucial role in documenting incidents within an agency. The primary objective of these reports is to ensure patient safety, uphold the...
827
01:25Drug Regulation
1.4K
Drug regulation encompasses the management of drug usage by evaluating its safety and efficacy through assessments conducted by regulatory authorities. Regrettably, the history of drug regulation is marred by several catastrophic events. One such incident is the Elixir Sulfanilamide tragedy, in which the toxic compound diethyl glycol was included in a sweet-tasting medication, leading to numerous fatalities. This event prompted the enactment of the Food, Drug, and Cosmetic Act in 1938. Under...
1.4K
01:12Hazard Ratio
116
The hazard ratio (HR) is a widely used measure in clinical trials to compare the risk of events, such as death or disease recurrence, between two groups over time. It reflects the ratio of hazard rates—the instantaneous risk of the event occurring—between a treatment group and a control group. This measure provides valuable insights into the relative effectiveness of a treatment by assessing how the risk of an event differs between the two groups.
For example, in a clinical trial...
For example, in a clinical trial...
116
01:26Types of Reports III: Telephone and Verbal Reports
738
Telephone and Verbal Reports in healthcare settings are two communication methods for conveying therapeutic instructions from healthcare providers to nurses or other healthcare staff.
Here's an overview of each type:
Telephone Orders
Here's an overview of each type:
Telephone Orders
738
01:21Factors Affecting Drug Response: Overview
2.0K
When it comes to infants and young children, they are typically administered smaller doses of medication in comparison to adults. This is primarily because their organ functions still need to fully develop, meaning their bodies are not as efficient at metabolizing or eliminating drugs. Additionally, their blood-brain barrier is more permeable than in adults. As a result, high concentrations of drugs can easily penetrate the central nervous system (CNS), potentially leading to neurological...
2.0K