Medication administration errors and the pediatric population: a systematic search of the literature

Medication administration errors are a serious concern for the pediatric population. This article presented an overview of medication errors and safe medication administration practices. Additional information was presented regarding the pediatric population and specific factors that make this population susceptible to medication errors. A systematic literature search on medication administration errors in the pediatric population was presented. From the search, five themes emerged, including the incidence rate of medication administration errors, specific medications involved in medication administration errors and classification of the errors, why medication administration errors occur, medication error reporting, and interventions to reduce medication errors.Differences in study design made it difficult to compare the articles with regard to some of the themes. However, it was apparent that medication administration errors do occur in the pediatric population, regardless of the exact incidence rate. As previously stated, the NCC MERP believes that there is no acceptable incidence rate for medication errors. Errors in dosage were found to be a common reason as to why medication errors occur. There was some discrepancy with regard to medication error reporting, as it was found that medication errors are underreported, but the extent of this varied. Systems used to report medication errors also varied. It was found that the more detailed the information reported on the medication error, the more potential impact it had on leading to a system change to prevent such errors from occurring again. It is recommended that reporting systems be nonpunitive so that nurses are not afraid to report errors. In addition, more emphasis should be placed on near miss medication errors, as these occur frequently but are rarely reported and may provide greater insight into system flaws. Lastly, interventions found to reduce medication administration errors were congruent with current recommendations for safe medication administration. This calls into question if the current recommendations are being followed uniformly. Implications for future research and practice include that a formalized system check for safe medication administration be developed and utilized. System checks have been developed and are widely used during the prescribing and preparing stage, and less medication errors are noted during this early part of the medication process. Having a formalized system check during medication administration would aid in ensuring that current recommendations are being followed, which would lead to a decrease in medication administration errors.Parents and caregivers naturally expect that their children will be safe when in the health care system. Yet, providing health care will always involve some degree of risk due to both the complexity of the health care environment and the role that human judgment plays within it. Nurses play a role in improving the safety of children within their care. The role of the nurse is much wider than simply reporting patient safety incidents or near misses; it includes taking preventative actions, sharing experiences, learning from mistakes, and helping to devise solutions.     

石家庄市社区多重用药老年人用药知识和用药行为的现状研究

目的：分析社区多重用药老年人用药知识和用药行为的现状及影响因素,为今后开展老年人的用药服务提供科学依据。方法：采用自行设计的社区老年人用药知识和行为调查问卷,对居住在社区的431例多重用药的老年人开展调查,采用t检验、多元线性回归分析结果。结果：社区多重用药老年人平均每日服药（6.50±1.65）种。其用药知识得分为（38.60±15.19）分,表现为对服药时间、管理药物的知识了解较少。社区多重用药老年人用药行为得分为（33.51±10.10）分,其按医嘱种类服药、管理药物和按时服药的行为较差。月收入、有医疗保险、受教育程度、男性是老年人用药知识的保护因素（P<0.05）。年龄是老年人用药知识的危险因素（P<0.05）,用药知识随年龄的增长而减少。女性是老年人用药行为的危险因素（P<0.05）。结论：社区多重用药老年人安全用药知识和用药行为现状不乐观,在做好用药服务工作中要多关注女性、低收入、无医疗保险的老年人。     

A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: A prospective observational study

BackgroundNo published study has been specifically designed to compare medication administration errors between original medication packaging and multi-compartment compliance aids in care homes, using direct observation.ObjectivesCompare the effect of original medication packaging and multi-compartment compliance aids on medication administration accuracy.DesignProspective observational.SettingTen Greater London care homes.ParticipantsNurses and carers administering medications.MethodsBetween October 2014 and June 2015, a pharmacist researcher directly observed solid, orally administered medications in tablet or capsule form at ten purposively sampled care homes (five only used original medication packaging and five used both multi-compartment compliance aids and original medication packaging). The medication administration error rate was calculated as the number of observed doses administered (or omitted) in error according to medication administration records, compared to the opportunities for error (total number of observed doses plus omitted doses).ResultsOver 108.4 h, 41 different staff (35 nurses, 6 carers) were observed to administer medications to 823 residents during 90 medication administration rounds. A total of 2452 medication doses were observed (1385 from original medication packaging, 1067 from multi-compartment compliance aids). One hundred and seventy eight medication administration errors were identified from 2493 opportunities for error (7.1% overall medication administration error rate). A greater medication administration error rate was seen for original medication packaging than multi-compartment compliance aids (9.3% and 3.1% respectively, risk ratio (RR) = 3.9, 95% confidence interval (CI) 2.4 to 6.1, p < 0.001). Similar differences existed when comparing medication administration error rates between original medication packaging (from original medication packaging-only care homes) and multi-compartment compliance aids (RR = 2.3, 95%CI 1.1 to 4.9, p = 0.03), and between original medication packaging and multi-compartment compliance aids within care homes that used a combination of both medication administration systems (RR = 4.3, 95%CI 2.7 to 6.8, p < 0.001). A significant difference in error rate was not observed between use of a single or combination medication administration system (p = 0.44).ConclusionThe significant difference in, and high overall, medication administration error rate between original medication packaging and multi-compartment compliance aids supports the use of the latter in care homes, as well as local investigation of tablet and capsule impact on medication administration errors and staff training to prevent errors occurring. As a significant difference in error rate was not observed between use of a single or combination medication administration system, common practice of using both multi-compartment compliance aids (for most medications) and original packaging (for medications with stability issues) is supported.     

自制护理用药安全手册用于患者安全管理

目的：了解目前临床用药中护理差错发生的原因,探索相应的对策以确保用药安全。方法针对2011年医院41个护理单元上报用药不良事件及11月开展用药安全专项检查存在的问题进行原因分析,制定用药安全手册,包括健全各种用药安全管理组织及制度,收集临床多品种、多规格、看似听似药品拍成图片进行比对,临床应控制滴速、接触易发生反应药物,药物配制信息,药物配伍禁忌,宜从中心静脉输注的药物,高危药物外渗紧急处理,抢救药物药理知识,以表格形式进行罗列。规范使用药物流程、组织培训与考核等一系列措施。结果2012年护理用药不良事件总数较2011年减少15起,下降18．5％。与2011年相比,2012年用药专项月检查存在问题,通过护理用药安全手册的制作与应用,加强了用药安全管理,促进护理人员掌握药品管理及用药知识,有效提高了护理人员用药安全能力,保障了患者用药安全。结论该手册为护士临床用药安全提供参考,起到临床用药指引作用,有效提高了护理人员用药能力。     

给药差错评分表的修订及其应用效果研究

目的：对给药差错评分表进行修订，探讨其临床应用效果。方法对2007年1月-2012年11月的给药差错案例进行整理、分析±组织召开专家论证会，基于统计结果对给药差错评分表进行论证和修订±采取历史对照研究方法，将2007年1月-2012年11月发生的84例给药差错作为对照组，2012年12月-2013年5月发生的8例给药差错作为观察组，采用修订后的给药差错评分表，比较两组在给药差错发生率的差异。结果给药差错评分表修订后，严重给药差错发生率、经静脉、肌内/皮下途径给药差错发生率、高危药品差错发生率分别由0．54，1．97，1．37，0．95/10万占用总床日数下降为0．00，0．62，0．62，0．00/10万占用总床日数，差异均有统计学意义（χ2分别为54．000，70．368，28．267，95．000;P＜0．01）。结论给药差错评分表的修订在一定程度上能够降低给药差错的发生率，但其长期应用效果还有待于进一步研究。     

药物自我处置训练对肺移植患者出院后服药依从性的影响

目的：探讨药物自我处置训练对肺移植患者服药依从性的影响。方法将48例肺移植患者随机分为试验组和对照组,每组24例。两组均接受常规护理干预,试验组在此基础上接受药物自我处置训练,比较两组干预效果。结果术后12个月时,试验组患者服药依从性为87．50％,对照组为79．17％,两组比较差异有统计学意义（χ2＝8．641,P＜0．05）;试验组血药浓度为（10．78±2．61） ng／L,6 min步行试验为（324．15±23．91）m,均高于对照组的（8．64±2．03）ng／L,（291．58±20．84）m,差异有统计学意义（t值分别为8．143,7．852;P＜0．05）。结论药物自我处置训练使患者掌握了服药的技术并养成了习惯,提高了服药依从性,适于临床推广应用。