如何利用生活经验来找出儿科口服液剂形式错误的原因
Anaëlle Dollo1, Jean-Philippe Rivière2, Sonia Prot-Labarthe3
1CHU Nantes, Service pharmacie, 44000 Nantes, France.
概括
由于说明和工具不清楚,护理人员在准备口服液体药物时犯了剂量错误. 改善药物包装和说明可以防止这些常见的儿科剂量错误.
科学领域:
- 儿科药理学 儿科药理学
- 药物安全 药物安全
- 人类因素工程 人类因素工程
背景情况:
- 口服液体剂量形式 (OLDF) 是儿童患者的首选.
- 护理人员的剂量错误在OLDF中很常见.
研究的目的:
- 调查OLDF复制和制备中剂量错误的原因.
- 确定导致儿科护理中药物管理错误的因素.
主要方法:
- 一项前性观察性定性研究,涉及17名参与者.
- 参与者准备了儿科口服液体药物 (阿莫西西林或阿莫西西林-克拉夫兰酸).
- 采用了微现象学采访和使用理性分类学进行错误分类.
主要成果:
- 确定了14个剂量错误,主要与测量匙,患者信息传单 (PIL) 和二次包装有关.
- 错误的主要来源包括剂量工具和药物瓶上的标记不清楚,以及令人困惑的PIL.
- 大多数错误被归类为基于规则的错误.
结论:
- 药物剂量错误是多因素的,涉及到明显的错误和误解.
- 参与者的经验突出了影响错误的认知和行为因素.
- 理性的分类是分析药物管理错误的宝贵工具.
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