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Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting system.
British Journal of Anaesthesia ( IF 9.8 ) Pub Date : 2019-11-25 , DOI: 10.1016/j.bja.2019.10.013
Yolanda Sanduende-Otero 1 , Javier Villalón-Coca 2 , Eva Romero-García 3 , Óscar Díaz-Cambronero 4 , Paul Barach 5 , Daniel Arnal-Velasco 6
Affiliation  

BACKGROUND Medication-related adverse events (MRE) in anaesthesia care are frequent and require a deeper understanding if we are to prevent medication harm. METHODS We searched for reported MRE from the Spanish Anaesthesia Incident Reporting System (SENSAR) database over a 10-yr period. SENSAR is a cross-national, multicentre system focused on perioperative and critical care. A descriptive analysis of independent variables, phase of medication process, type of MRE, and medication group involved, and their relationships with morbidity was conducted. RESULTS A total of 1970 MRE were identified from 7072 reported incidents. Patient harm was reported in 31% of the MRE. The administration phase was more frequent (42%) and showed the highest harm rate (44%) compared with other medication process phases. The most frequent types of MRE were wrong treatment regimen and wrong medication (55% of cases). The medication groups most commonly reported were those that alter haemostasis (18%), vasoconstrictor agents (13%), and opioids (10%). Vasoconstrictor agents, benzodiazepines, and neuromuscular blocking agents were the medication groups involved in patient harm four-fold more, and opioids three-fold more, than medications that alter haemostasis. The 1970 incidents were investigated and led to implementation of 4223 local corrective patient safety and quality improvement measures. CONCLUSIONS Patient harm in the perioperative setting from medications remains a major issue for patients, hospital leaders, and clinicians. We found patterns and specific causes that can be mitigated through proven systems solutions, and should be taken into consideration in designing sustainable solutions for safe perioperative care. CLINICAL TRIAL REGISTRATION NCT03615898.

中文翻译:

药物事件的模式:跨麻醉事件报​​告系统的10年经验。

背景技术麻醉护理中与药物相关的不良事件(MRE)很常见,如果我们要预防药物伤害,则需要更深入的了解。方法我们从西班牙麻醉事件报​​告系统(SENSAR)数据库中搜索了10年以上报告的MRE。SENSAR是一个专注于围手术期和重症监护的跨国,多中心系统。对自变量,用药过程的阶段,MRE的类型和所用用药组及其与发病率的关系进行描述性分析。结果从7072例报告的事件中总共识别出1970例MRE。据报告,在MRE中有31%的患者受到伤害。与其他药物治疗阶段相比,给药阶段更为频繁(42%),并且显示出最高的伤害率(44%)。MRE最常见的类型是错误的治疗方案和错误的药物治疗(占病例的55%)。最常报告的药物组是改变止血(18%),血管收缩药(13%)和阿片类药物(10%)的药物组。血管收缩剂,苯二氮卓类药物和神经肌肉阻滞剂是与改变止血药物相比,对患者造成伤害的药物组高出四倍,而阿片类药物的危害高出三倍。对1970年的事件进行了调查,并导致实施了4223项本地纠正性患者安全和质量改善措施。结论药物对围手术期患者的伤害仍然是患者,医院领导和临床医生的主要问题。我们发现可以通过成熟的系统解决方案来缓解的模式和特定原因,在设计安全围手术期护理的可持续解决方案时应予以考虑。临床试验注册NCT03615898。
更新日期:2019-12-17
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