بررسی خطاهای دارویی در بخش های داخلی بیمارستان امام سجاد(ع) رامسر در بهار و تابستان 1396

نوع مقاله : مقاله پژوهشی

نویسندگان

1 دانشیار فارماکولوژی، گروه فارماکولوژی، دانشکده پزشکی، دانشگاه علوم پزشکی گیلان، رشت ، ایران

2 دکتر داروساز، کمیته تحقیقات دانشجویی، پردیس رامسر، دانشگاه علوم پزشکی مازندران، رامسر، ایران

3 استاد داروسازی بالینی، گروه داروسازی بالینی، دانشکده داروسازی، دانشگاه علوم پزشکی مازندران، ساری، ایران

چکیده

مقدمه
اشتباهات دارویی رخداد شایع بالقوه خطرناک است که می‎تواند در سیستم درمان به عنوان یکی از چالش‎ها ‎و معیارهای سنجش ایمنی بیمار مورد استفاده قرار گیرد.در این مطالعه، برخی از خطاهای رایج دارویی در بخش‎های داخلی بیمارستان امام سجاد (ع) رامسر، مورد بررسی قرار گرفت.
روش کار
نوع مطالعه توصیفی- مقطعی و جامعه مورد مطالعه شامل200پرونده بیمار بستری در بخش داخلی بیمارستان سجاد رامسر در فاصله زمانی بهار و تابستان سال 1396 بود. اطلاعات جمع آوری شده شامل اطلاعات دموگرافیک بیماران از پرونده، دستورات دارویی  ثبت شده در پرونده بیمار و دستورات دارویی منتقل شده به کاردکس دارویی بیمار بود. جهت تعیین تداخلات دارویی و شدت عوارض  از Medscape استفاده شد. 
نتایج
در مجموع 200 پرونده‎، 1888 مورد تجویز دارو از بین 112 قلم داروی مختلف صورت گرفت. 166 مورد تداخل دارویی مشاهده شد. افزایش تعداد اقلام دارویی و افزایش تعداد روزهای بستری با بروز تداخلات دارویی ارتباط معنی دار داشت(05/0>p). از 1720 دستور دارویی ثبت شده توسط پزشکان،  223 خطای دارویی در بخش داخلی توسط پزشکان و 36 خطای در اجرای بازنویسی دستورات دارویی و دارو دهی توسط پرستاران ثبت شد. بیشترین تعداد خطای رخ داده توسط تیم پزشکی 1/86% رخ داد و سهم تیم پرستاری در بروز خطای رونویسی و اجرای دستورات دارودهی 9/13% بود.
نتیجه ­گیری
بازخورد مناسب نتایج این مطالعه می‎تواند در کاهش خطاهای دارویی پزشکان و پرستاران اثرگذار و ارزشمند باشد.

کلیدواژه‌ها


عنوان مقاله [English]

Evaluation of Medication Errors in Internal Wards of Imam Sajjad Ramsar Hospital In 2017 Spring and Summer

نویسندگان [English]

  • Nematollah Ahangar 1
  • Setareh Ghorbanian khorshidi 2
  • Shahram ALa 3
1 Associate Professor of Pharmacology, Department of Pharmacology, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
2 Pharmacist, Student Researches Committee, Ramsar Campus, Mazandaran University of Medical Sciences, Ramsar, Iran
3 Professor of Clinical Pharmacy, Department of Clinical Pharmacy,Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
چکیده [English]

Introduction: Drug errors are a potentially hazardous occurrence that can be used in the treatment systems as one of the challenges and criteria for patient safety assessment. In this study, some of the main medication errors were evaluated in internal wards of Ramsar Imam Sajjad Hospital.
Materials and Methods: This was a descriptive prospective cross- sectional study. Subjects were including 200 files of patients hospitalized in internal wards of Imam Sajjad hospital between March and September 2017. Gathered data were including demographic data obtained from patient’s file, drug orders documented in patient’ s file and drug orders transferred to patient’s drug cardex. Medscape was used for evaluating of any drug interactions.
Results: A total of 1888 prescribing were noted from 112 different drugs, in overall 200 investigated files, 166 cases of drug interaction were noted. There was significant relationship between number of drug use and hospitalization period with detection of drug interaction (p<0.05). Of 1720 registered orders, 223 medication errors occurred by the physicians and 36 errors by the nurses in drug transcription and administration. Physicians’ contribution in medication error was more (86.1 %). Nurses ’contribution in transcription error and drug order running was 13.9 %.  
Conclusion: Appropriate feedback of results of the present study could be effective and valuable in reducing medication error.

کلیدواژه‌ها [English]

  • Drug order
  • Imam Sajjad hospital
  • Internal ward
  • Iran
  • Medication error
  • Ramsar
1-Härkänen M, Turunen H, Saano S, VehviläinenJulkunen K . Detecting medication errors: Analysis
based on a hospital's incident reports. Int J Nurs
Pract. 2015;21(2):141-6. doi: 10.1111/ijn.12227
2-Penjvini S. Investigation of the rate and type of
medication errors of nurses in sanandaj hospitals. IJNR
2006;1(1):59-64.
3-Grissinger MC, Kelly K . Reducing the risk of
medication errors in womenJ Womens Health
(Larchmt). 2005;14(1):61-7
4- Abbasinazari M, Hajhossein Talasaz A,Eshraghi
A,Sahraei Z. Detection and Management of Medication
Errors in Internal Wards of A Teaching Hospital by
Clinical Pharmacists. Acta Med Iran .2013; 51)7(:482-
6.
5- Mansouri A, Ahmadvand A, Hadjibabaie M, Kargar
M, Javadi M, Gholami K. . Types and Severity of
Medication Errors in Iran; a Review of the Current
Literature. Daru. 2013;21(1):49. doi: 10.1186/2008-
2231-21-49
6- Kaushal R, Bates DW, Landrigan C, McKenna
KJ, Clapp MD, Federico F,et al . Medication errors and
adverse drug events in pediatric inpatients.
JAMA. 2001;285(16):2114-20.
7-Stratton KM, Blegen MA, Pepper G, Vaughn T .
Reporting of medication errors by pediatric nurses. J
Pediatr Nurs. 2004;19(6):385-92.
8-National Coordinating Council for Medication Error
Reporting and Prevention .Available
at://www.nccmerp.org
9- Ghasemi F, Valizadeh F, Moemen Nasab M.
Analyzing the knowledge and attitude of nurses
regarding medication error and its prophylactic ways in
educational and therapeutic hospitals of Khorramabad.
yafte. 2009; 10 (2) :55-63.
10-Kouhestani H, Baghcheghi N. Refusal in reporting
medication errors from the viewpoints of nursing
students in Arak university of medical sciences. IJME
2009;8(2):285-92.
11- Mohammad Nejad I, Hojjati H, Sharifniya S H,
Ehsani S R. Evaluation of medication error in nursing students in four educational hospitals in Tehran. ijme.
2010; 3 (1 and 2) :60-69
12- Guchelaar HJ, Colen HB, Kalmeijer MD, Hudson
PT, Teepe-Twiss IM. Medication errors: Hospital
pharmacist perspective. Drugs. 2005;65(13):1735-46.
13- ASHP guidelines on preventing medication errors
in hospitals. Am J Hosp Pharm. 1993 Feb;50(2):305-
14.
14-Barker KN, Flynn EA, Pepper GA, Bates
DW, Mikeal RL . Medication errors observed in 36
health car facilities. Arch Intern Med. 2002; 162(16):
1897- 903.
15- Meurier CE, Vincent CA, Parmar DG. Learning
from errors in nursing practice. J Adv Nurs. 1997;
26(1): 111-9.
16- Hoffman JM, Proulx SM. . Medication errors
caused by confusion of drug names. Drug Saf. 2003;
26(7): 445-52.
17- Mirfarhadi N, Moosavi S, Tabari R, Kazemnejad
E. Predictive factors of job satisfaction among nurses
in therapeutic-educational centers of Guilan University
of Medical Science. J Neyshabur Univ Med Sci. 2014;
2 (4) :27-35.
18- Fung A. Medical errors cost health care system
billions. National Journal Health Care, National
Journal online. 2011 Apr 7.
19- To Err Is Human: Building a Safer Health System.
Institute of Medicine (US) Committee on Quality of
Health Care in America; Kohn LT, Corrigan
JM, Donaldson MS, editors.Washington (DC):
National Academies Press (US); 2000.
20- Fogarty GJ, Mckeon CM. Patient safety during
medication administration: the influence of
organizational and individual variables on unsafe work
practices and medication errors. Ergonomics. 2006 Apr
15;49(5-6):444-56.
21-Van Den Bos J, Rustagi K, Gray T, Halford
M, Ziemkiewicz E, Shreve J. The $17.1 billion
problem: the annual cost of measurable medical errors.
Health Aff (Millwood). 2011;30(4):596-603. doi:
10.1377/hlthaff.2011.0084.
22- Errors PM. Quality Chasm Series. Committee on
Identifying and Preventing Medication Errors. Aspden
P, Wolcott J, Bootman JL, Cronenwett LR, eds.
Institute of Medicine. 2006 Jul.
23- Gahremani R, Sharifi H. INVESTIGATING THE
PREVALENCE OF MEDICATION ERRORS IN
PREPARATION AND THE ADMINISTRATION OF
INTRAVENOUS DRUGS IN A SECOND-LEVEL
UNIVERSITY HOSPITAL. J Urmia Univ Med Sci.
2016; 27 (2) :140-7
24- Valizadeh F, Ghasemi SF, Nagafi SS, Delfan B,
Mohsenzadeh A. Errors in medication orders and the
nursing staff's reports in medical notes of children.
Iranian Journal of Pediatrics. 2008;18(Suppl 1):33-40.
25-Osmon S, Harris CB, Dunagan WC, Prentice D,
Fraser VJ, Kollef MH. Reporting of medical errors: an
intensive care unit experience. Crit Care
Med. 2004;32(3):727-33.
26- Rahimi B, Gharabaghi N, Hesari Z, Balanji S,
Alinia T. PREVALENCE OF POTENTIAL DRUG
INTERACTIONS IN PATIENTS IN THE
INTENSIVE CARE UNIT OF URMIA TALEGHANI
HOSPITAL. J Urmia Univ Med Sci. 2013; 24 (2) :133-
145.
27- Rafieii H, Arab M, Ranjbar H, Arab N, Sepehri G,
Amiri M. The prevalence of potential drug interactions
in Intensive Care Units. Iran J Crit Care Nurs .
2012;4(4):191-6.