Die Prävalenz von Medikationsfehlern in der stationären Rehabilitation: Eine Beobachtungsstudie

IF 1.5 Q4 HEALTH POLICY & SERVICES

Zeitschrift fur Evidenz Fortbildung und Qualitaet im Gesundheitswesen Pub Date : 2026-09-01 Epub Date: 2026-06-24 DOI:10.1016/j.zefq.2026.05.007

Sabrina Kathriner, Raffael Bisig

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Abstract

Introduction

Medication errors are among the most frequent preventable risks in healthcare. Data on error rates in inpatient rehabilitation settings have so far been limited.

Methods

A disguised direct observational study was conducted in a rehabilitation clinic, complemented by retrospective prescription analysis. Three medication process steps were observed: prescribing, preparation, and administration. Errors were classified according to NCC MERP severity categories.

Results

A total of 466 opportunities of error (OE) were examined. The error rate was 26.8 % (95 % CI: 20.2–32.6), with 148 errors recorded. Most errors occurred with prescribing (56 %), followed by preparation (24 %), and administration (20 %). Category C errors were most frequent (41.2 %), followed by B (29.7 %) and E (26.4 %). No severe errors (categories F–I) were observed. Factors such as ward, medication timing, and nursing experience showed no significant effect.

Discussion

The error rate corresponds to approximately one error per four medication doses and is comparable to international findings. The high proportion of prescribing errors indicates structural weaknesses in the medication process.

Conclusion

The findings highlight the urgent need to improve medication safety in inpatient rehabilitation. Implementing a closed-loop medication process with electronic prescribing, unit-dose packaging, and barcode scanning is recommended.

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药物滥用：一项观察性研究。

用药错误是医疗保健中最常见的可预防风险之一。迄今为止，关于住院康复机构错误率的数据有限。方法：在某康复诊所进行直接观察性研究，并辅以回顾性处方分析。观察三个用药过程步骤：处方、制备和给药。根据NCC MERP严重性类别对错误进行分类。结果：共检查了466个错误机会（OE）。错误率为26.8 %(95 % CI: 20.2-32.6)，记录错误148次。大多数错误发生在处方（56 %），其次是制剂（24 %）和给药（20 %）。C类错误发生率最高（41.2 %），其次是B类（29.7 %）和E类（26.4 %）。未观察到严重错误（F-I类）。病区、用药时间、护理经验等因素无显著影响。讨论：错误率大约相当于每4次用药剂量出现一次错误，与国际研究结果相当。处方错误的高比例表明在用药过程中的结构性弱点。结论：提高住院康复患者用药安全的必要性。建议采用电子处方、单位剂量包装和条形码扫描的闭环用药流程。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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