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如何克服药物错误低估? 如何克服药物错误低估? 改善药物错误指数,重点是血液造血干细胞移植环境中的静脉注射药物;直接观察研究
Ava Mansouri1, Kiana Moazzeni2, Maryam Valeh1
1Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran.
PloS one
|August 22, 2024
概括
药物错误在静脉注射 (IV) 药物制备和在血造干细胞移植 (HSCT) 设置中的药物管理过程中很常见. 这项研究确定了容易出错的关键步骤,突出了提高患者安全的有针对性的预防措施的需要.
科学领域:
- 药监和患者安全 药监和患者安全
- 血液学和瘤学 药房实践 药房实践
- 医学错误的流行病学医学错误的流行病学
背景情况:
- 静脉注射 (IV) 药物管理是复杂的,容易出现错误,特别是在血液造血干细胞移植 (HSCT) 中,患者的免疫力受损.
- 在HSCT中药物错误 (ME) 可能导致严重的不良事件,包括死亡,需要准确的检测和分析.
- 现有的ME研究往往存在方法上的局限性,使得可靠的解释具有挑战性.
研究的目的:
- 解决在HSCT中IV药物管理期间研究药物错误的方法挑战.
- 通过精确的流行病学方法和新的分母来识别和量化药物错误.
- 确定在HSCT病房内制备和服用IV药物的特定易出错的步骤.
主要方法:
- 一项观察性,横截面研究,涉及对525次静脉注射药物治疗事件的隐蔽直接观察.
- 临床药剂师对3个HSCT病房的32种不同的静脉注射药物的评估.
- 使用了三个错误比率:总错误机会 (TOE),比例错误比率和纠正的总错误机会 (CTOE).
主要成果:
- 在5347个潜在错误中,共发现了1568个错误.
- 错误的总机会 (TOE) 为298%,纠正的错误的总机会 (CTOE) 为29.3%.
- 大多数错误发生在给药阶段,常见问题包括错误的溶剂量和不充分的监测.
结论:
- 药物错误在HSCT环境中常见于IV药物的制备和使用.
- 该研究成功地使用精细的检测方法和分母识别了易出错的关键步骤.
- 实施有针对性的预防策略对于提高HSCT患者安全至关重要,这些发现为此类干预提供了基础.
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