涉及高警惕性药物的儿科用药差错的影响因素:自我报告用药安全事件的定性内容分析

IF 2.8 3区 医学 Q1 PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH
Sini Kuitunen, Mari Saksa, Anna-Riia Holmström
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引用次数: 0

摘要

背景:高警惕性药物可导致儿科严重用药错误(MEs)。建立风险管理行动需要全面了解导致错误的因素。目的:分析涉及高危药物的儿科MEs事件报告,并描述其影响因素(CFs)。方法:采用回溯性文献分析方法,对某儿科大学附属医院2018 - 2020年高危药物自述用药安全事件进行定性内容分析。事件报告(n = 426)首先进行归纳定性内容分析,以识别和分类CFs,然后根据频率和百分比进行量化,最终根据患者安全系统工程倡议(SEIPS)模型的要素进行演绎分类。该分析首先由一名独立研究人员进行,然后由另一名研究人员进行审查,后来由整个研究小组进行审查。结果:共发现CFs 933例,占事件报告的85.0% (n = 362/426)。最常见的CFs主要类别与验证正确的药物(11.1%,n = 104/933)、药物和药品(10.6%,n = 99/933)和资源(10.5%,n = 98/933)有关。超过一半的cf与涉及任务(39.6%,n = 370)和工具和技术(20.8%,n = 194)的SEIPS要素相关。结论:涉及高警惕性药物的儿科MEs的CFs是多方面的,对整个系统设计具有广泛的影响,从组织策略到个人任务。风险管理行动和针对儿科特定挑战的进一步研究需要确保最优的系统防御,从而在临床实践中主动监测引起错误的条件。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Contributing factors of pediatric medication errors involving high-alert medications: A qualitative content analysis of self-reported medication safety incidents.

Background: High-alert medications can cause severe medication errors (MEs) in pediatrics. A comprehensive understanding of the factors contributing to errors is needed to establish risk management actions.

Objective: To analyze incident reports involving high-alert medications and describe the contributing factors (CFs) of MEs in pediatrics.

Methods: A retrospective document analysis study utilizing an abductive qualitative content analysis of self-reported medication safety incidents concerning high-alert medications at a pediatric university hospital from 2018 to 2020. Incident reports (n = 426) were first subjected to an inductive qualitative content analysis to identify and categorize CFs, then quantified by frequencies and percentages, and ultimately deductively categorized based on the elements of the Systems Engineering Initiative for Patient Safety (SEIPS) model. The analysis was first conducted by one independent researcher, then reviewed by a second researcher, and later reviewed by the entire research group.

Results: A total of 933 CFs were identified, concerning 85.0 % (n = 362/426) of the incident reports. The most common main categories of CFs pertained to verifying the correct drug (11.1 %; n = 104/933), medications and pharmaceuticals (10.6 %; n = 99/933), and resourcing (10.5 %; n = 98/933). Over half of the CFs were linked to SEIPS elements involving tasks (39.6 %, n = 370) and tools and technologies (20.8 %, n = 194).

Conclusions: The CFs of pediatric MEs involving high-alert medications are multifaceted and have a wide impact on the entire system design, from organizational strategies to individual tasks. Risk management actions and further studies addressing pediatric-specific challenges are required to ensure the most optimal systemic defenses, enabling proactive monitoring error-provoking conditions in clinical practice.

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来源期刊
Research in Social & Administrative Pharmacy
Research in Social & Administrative Pharmacy PUBLIC, ENVIRONMENTAL & OCCUPATIONAL HEALTH-
CiteScore
7.20
自引率
10.30%
发文量
225
审稿时长
47 days
期刊介绍: Research in Social and Administrative Pharmacy (RSAP) is a quarterly publication featuring original scientific reports and comprehensive review articles in the social and administrative pharmaceutical sciences. Topics of interest include outcomes evaluation of products, programs, or services; pharmacoepidemiology; medication adherence; direct-to-consumer advertising of prescription medications; disease state management; health systems reform; drug marketing; medication distribution systems such as e-prescribing; web-based pharmaceutical/medical services; drug commerce and re-importation; and health professions workforce issues.
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