Hospital admission leads to drug errors
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《英国医生杂志》
In over half of hospital admissions of elderly people in Canada, drug errors occur at the time of admission, including some potentially harmful changes in drugs or dosages, warned a recent study ( Archives of Internal Medicine 2005;165: 424-9). Researchers from the University of Toronto screened the medical charts of all patients admitted on an unplanned basis to the general internal medical clinics of a 1000 bed teaching hospital over a three month period. They included 151 patients (mean age 77 years), out of 523 screened, who said they regularly took at least four prescription drugs and who were able to communicate themselves or via a caregiver.
A researcher visited the patient at least 48 hours after admission, to allow time for any admission drug orders to be clarified and any problems in the normal course of care to be corrected, and conducted a thorough history of their regular drug use, an inspection of prescription phials, and follow-up with a community pharmacy. Any discrepancies were reviewed with the medical team to determine if they were intentional or unintentional.
Overall, 81 patients (54%, 95% confidence interval 46% to 62%) had at least one unintended discrepancy, with a total of 140 unintended discrepancies in total. Most discrepancies were for cardiovascular drugs (27%) and central nervous system drugs (26%). The most common error (46%) was omission of a regularly used medication.
Most (61%) of the discrepancies were judged to have no potential to cause serious harm. However, 39% of the discrepancies were considered to have the potential to cause moderate to severe discomfort or clinical deterioration.
Examples of the discrepancies found included two patients who continued taking their own non-steroidal anti-inflammatory drugs without the admitting doctor's knowledge after being hospitalised for gastrointestinal haemorrhage. One patient's prednisone was omitted, and one was prescribed an incorrect drug because tablets were stored in prescription phials labelled for other drugs.(Susan Mayor)
A researcher visited the patient at least 48 hours after admission, to allow time for any admission drug orders to be clarified and any problems in the normal course of care to be corrected, and conducted a thorough history of their regular drug use, an inspection of prescription phials, and follow-up with a community pharmacy. Any discrepancies were reviewed with the medical team to determine if they were intentional or unintentional.
Overall, 81 patients (54%, 95% confidence interval 46% to 62%) had at least one unintended discrepancy, with a total of 140 unintended discrepancies in total. Most discrepancies were for cardiovascular drugs (27%) and central nervous system drugs (26%). The most common error (46%) was omission of a regularly used medication.
Most (61%) of the discrepancies were judged to have no potential to cause serious harm. However, 39% of the discrepancies were considered to have the potential to cause moderate to severe discomfort or clinical deterioration.
Examples of the discrepancies found included two patients who continued taking their own non-steroidal anti-inflammatory drugs without the admitting doctor's knowledge after being hospitalised for gastrointestinal haemorrhage. One patient's prednisone was omitted, and one was prescribed an incorrect drug because tablets were stored in prescription phials labelled for other drugs.(Susan Mayor)