An observational study to identify drug-related problems (DRP) in routine care and an expert panel assessment to rate clinical risk and preventability by unit-dose dispensing systems (UDDS) with computerized physician order entry (CPOE) and clinical decision-support systems (CDSS)

被引：3

作者：

Wildhagen, F., V ^{[1
]}

Neininger, M. P. ^{[2
,3
,4
]}

Hensen, J. ^{[1
]}

Steinbeck, A. ^{[1
]}

Zube, O. ^{[1
]}

Bertsche, T. ^{[2
,3
,4
]}

机构：

[1] Bundeswehr Hosp, Hamburg, Germany

[2] Univ Leipzig, Inst Pharm, Med Fac, Clin Pharm, Bruderstr 32, D-04103 Leipzig, Germany

[3] Univ Leipzig, Drug Safety Ctr, Bruderstr 32, D-04103 Leipzig, Germany

[4] Leipzig Univ Hosp, Bruderstr 32, D-04103 Leipzig, Germany

来源：

PHARMAZIE | 2023年 / 78卷 / 08期

关键词：

MEDICATION PROCESS; PATIENT SAFETY;

D O I：

10.1691/ph.2023.3557

中图分类号：

R914 [药物化学];

学科分类号：

100701 ;

摘要：

Background and aim: Drug-related problems (DRP) jeopardize patient safety. Unit-dose dispensing systems (UDDS) with computerized-physician-order-entry (CPOE) and clinical-decision-support-systems (CDSS) were reported as a promising concept for preventing DRP. We aimed at identifying and categorizing DRP in peroral drug administration considering their clinical risk and preventability by UDSS/CPOE/CDSS. Investigations: In surgical and internal-medicine departments, we observed routine procedures in peroral drug administration for DRP. An expert panel including pharmaceutical and nursing expertise categorized the identified 18 DRP categories into three levels: DRP that have not yet resulted in medication errors (ME) (Level-I), DRP where ME have occurred but have not yet reached the patient (Level-II), and DRP where ME have occurred and have reached the patient (Level-III). Additionally, the panel categorized DRP according to their clinical risk and whether the implementation of UDSS/CPOE/CDSS can prevent them. Results: In 77 surgical patients, 1,849 peroral drug administration procedures, and in 149 internal-medicine patients, 1,405 procedures were observed. The 18 DRP categories were identified with a frequency of 0.6%-26.7% (Level-I), 0.1%-21.5% (Level-II), and 0.0%-1.0% (Level-III). Of those, four categories were considered of high clinical risk: "Name of the medication is not readable", "Prescribed medication is not prepared for administration", "An incorrect or non-prescribed medi-cation is prepared", and "A medication is prepared for the wrong patient (mix-up)". Twelve DRP categories were categorized as highly preventable by UDSS/CPOE/CDSS. Conclusions: Under routine conditions, we identified a substantial number of DRPs. An expert panel categorized many of those DRPs as clinically highly relevant and highly preventable by UDSS/CPOE/CDSS.

引用

页码：134 / 140

页数：7