识别与肠道营养素有关的问题,使用来自社区药房的近乎错过事件数据库
Shingo Kondo1,2, Mari Maese1, Hiroki Iwata1,2
1Division of Social Pharmacy, Center for Social Pharmacy and Pharmaceutical Care Sciences, Faculty of Pharmacy, Keio University, Tokyo, Japan.
涉及肠道营养素的近乎失误事件很常见,通常与禁忌和不良反应有关. 药剂师必须保持警,以确保为需要营养支持的患者提供安全的药物治疗.
科学领域:
- 临床药房 临床药房
- 患者安全 患者安全
- 营养支持营养支持
背景情况:
- 营养不良是手术后或当难以口服时存在的重大风险.
- 肠道营养素对于营养管理至关重要,但有 kontraindications 和 需要小心配方.
- 社区药房中与营养有关的事件的频率在很大程度上是未知的.
研究的目的:
- 为了确定需要肠道营养的患者在药物治疗中的安全问题.
- 用日本数据库分析与肠道营养相关的近乎失误事件.
- 为药剂师提供关键信息,以防止药物错误.
主要方法:
- 利用该项目收集和分析制药近错事件信息数据库.
- 从2009年1月到2023年9月,搜索了与"营养 (包括所有) "相关的案例.
- 将事件分类为"关于处方的调查" (第二类) 和"药物发行" (第一类).
主要成果:
- 报告有475例病例,其中73%属于II类,24%属于I类.
- 在这两类药物中,肠道营养素是两类药物中排名第一的药物.
- 关键的II类病例包括病理性禁忌 (9),腹 (6) 和过敏 (5) 等不良反应.
- 不良反应发生率超过了最近的年度报告.
结论:
- 药剂师在开处方肠道营养时,必须高度意识到潜在的禁忌.
- 处方时的警对于防止错误和确保安全的药物治疗至关重要.
- 解决近乎失误事件可以提高社区药房设置中的患者安全.
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