Incidents et accidents médicamenteux en établissement de santé : une analyse descriptive au sein d’un CHU mère-enfant de 2018 à 2022

Charlotte Maurin, Suzanne Atkinson, Linda Hamouche, Jean-François Bussières
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Abstract

Background The safety of care provided is based on an analysis of medication incidents and accidents. Objective The primary objective was to describe medication-related incidents and accidents (I&A) within a university-affiliated hospital. Methods This retrospective descriptive study was based on data from a 500-bed mother-child university-affiliated hospital. All I&As declared between April 1, 2018, and March 31, 2022, were considered. The analysis included all medication-related I&As that occurred during an admission or in an outpatient setting. Some variables were recoded manually. Descriptive statistical analyses were performed. Results A total of 23 284 I&As were considered, including 7578 medication-related I&As. Daily averages of 15.9 ± 14.0 I&As and 5.2 ± 0.3 medication-related I&As were reported. There were 22.4 medication-related I&As/1000 inpatient days. The majority of medication-related I&As occurred in surgery (20%, 1530/7578), oncology (19%, 1405/7578), and pediatrics (16%, 1200/7578). Most were associated with incorrect dosing (21%, 1575/7578); infiltration, extravasation, or removed lines (19%, 1405/7578); and omissions (16%, 1205/7578). Physical consequences were reported in 15% (1158/7578) of the medication-related I&As. Conversely, psychological consequences were reported in less than 1% (44/7578) of medication-related I&As. Conclusions This study provides a comprehensive descriptive profile over a 4-year period. Most of the reported I&As did not lead to consequences for patients. The sharing of ratios promotes comparative analysis with other facilities and can contribute to discussions about risk reduction. A culture of reporting events is present within this health care facility.
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医疗机构的用药事件和事故:2018年至2022年一所大学妇幼医院的描述性分析
背景医疗服务的安全性基于对用药事件和事故的分析。目的主要目的是描述一家大学附属医院内与用药相关的事件和事故(I&A)。研究考虑了2018年4月1日至2022年3月31日期间申报的所有I&A。分析包括入院期间或门诊环境中发生的所有与药物相关的并发症。部分变量经人工重新编码。结果共考虑了 23 284 例 I&A,其中包括 7578 例与药物相关的 I&A。报告的日平均 I&As 为 15.9 ± 14.0,与药物相关的 I&As 为 5.2 ± 0.3。每千个住院日有 22.4 例与药物相关的误诊误治。大多数与用药相关的误服误判发生在外科(20%,1530/7578)、肿瘤科(19%,1405/7578)和儿科(16%,1200/7578)。大多数与用药错误(21%,1575/7578)、浸润、外渗或移行(19%,1405/7578)和遗漏(16%,1205/7578)有关。15%(1158/7578)的药物相关 I&As 报告了身体后果。与此相反,在与用药相关的 I&As 中,心理后果的报告不到 1%(44/7578)。大多数报告的误诊误治并未对患者造成后果。比率的共享促进了与其他机构的比较分析,并有助于有关降低风险的讨论。在这家医疗机构中,存在着一种报告事件的文化。
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