梅托克洛普拉米德处方错误的案例研究:一个严峻的提醒
Florent Wallet1, Charlotte Doudet2, Alexandre Theissen3
1PHE3ID, Centre International de Recherche en Infectiologie, Service d'Anesthésie Réanimation - Médecine Intensive, Institut National de la Santé et de la Recherche Médicale U1111, CNRS Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France.
由于过时的库,发生了计算机化提供者订单输入 (CPOE) 药物错误. 积极的药物管理和药剂师整合对于患者安全至关重要.
科学领域:
- 医疗信息学 医疗信息学
- 患者安全 患者安全
- 临床药房 临床药房
背景情况:
- 计算机化提供者订单输入 (CPOE) 系统对于患者安全和减少药物错误至关重要.
- 由于CPOE系统中的特定监督,由于未更新的药物库,允许对已停产的梅托克洛普拉米德配方 (100毫克) 处方.
研究的目的:
- 描述和分析与过时的CPOE药物库相关的处方错误.
- 调查梅托克洛普拉米德100毫克处方错误的频率和情况.
主要方法:
- 从2014年到2023年对所有梅托克洛普拉米德处方的回顾性分析.
- 对于100毫克或更高的剂量,计算每1000处方的错误率.
主要成果:
- 涉及梅托克洛普拉米德100毫克或更高的错误很少发生 (1000处方中有2.98例).
- 其中47.1%的错误发生在值班期间,68%的错误导致实际管理.
- 与护士工作量增加相关的错误.
结论:
- 过时的CPOE药物库存在药物错误的风险.
- 将专门的药剂师整合到重症监护病房,并实施积极的药物管理,可以提高患者的安全性和结果.
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