A Case-Study of Metoclopramide Prescription Error : A Grim Reminder.

IF 3.5 3区医学 Q1 HEALTH CARE SCIENCES & SERVICES Journal of Medical Systems Pub Date : 2024-08-22 DOI:10.1007/s10916-024-02099-3

Florent Wallet, Charlotte Doudet, Alexandre Theissen, Arnaud Friggeri, Charles-Hervé Vacheron

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Abstract

The integration of Computerized Provider Order Entry (CPOE) systems in hospitals has been instrumental in reducing medication errors and enhancing patient safety. This study examines the implications of a software oversight in a CPOE system : Metoclopramide had a concentrated formulation (100 mg) delisted (and then not manufactured) in 2014 due to safety concerns. Despite this, the CPOE system continued to accept prescriptions for this formulation because it was not removed from the medication library by the pharmacist. The objective of our study was to describe this specific prescription error related to an outdated the medication library of the CPOE. We analyzed all metoclopramide prescriptions from 2014, to 2023. Our findings showed that errors involving 100 mg or more dosages were relatively rare, at 2.98 per 1000 prescriptions (34 errors in 11,372 prescriptions). Notably, 47.1% of these errors occurred during on-call shifts, and 68% of these errors led to actual administration. These errors correlated with periods of higher nurse workload. The findings advocate for the integration of dedicated pharmacists into ICU teams to minimize medication errors and enhance patient outcomes, and a proactive medication management in healthcare.

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甲氧氯普胺处方错误案例研究：一个严峻的提醒。

医院整合计算机化医嘱输入系统（CPOE）在减少用药错误和提高患者安全方面发挥了重要作用。本研究探讨了 CPOE 系统软件疏忽的影响：出于安全考虑，甲氧氯普胺的浓缩制剂（100 毫克）于 2014 年退市（随后不再生产）。尽管如此，CPOE 系统仍继续接受这种制剂的处方，因为药剂师并未将其从药物库中删除。我们的研究旨在描述这种与 CPOE 药物库过时有关的特殊处方错误。我们分析了从 2014 年到 2023 年的所有甲氧氯普胺处方。我们的研究结果表明，涉及 100 毫克或以上剂量的错误相对较少，每 1000 张处方中只有 2.98 例（11372 张处方中出现 34 例错误）。值得注意的是，47.1% 的错误发生在值班期间，其中 68% 的错误导致了实际用药。这些错误与护士工作量较大的时期有关。研究结果提倡将专职药剂师纳入重症监护室团队，以最大限度地减少用药错误，提高患者的治疗效果，并在医疗保健中积极主动地进行用药管理。

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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来源期刊

Journal of Medical Systems 医学-卫生保健

CiteScore

11.60

自引率

1.90%

发文量

审稿时长

4.8 months

期刊介绍： Journal of Medical Systems provides a forum for the presentation and discussion of the increasingly extensive applications of new systems techniques and methods in hospital clinic and physician''s office administration; pathology radiology and pharmaceutical delivery systems; medical records storage and retrieval; and ancillary patient-support systems. The journal publishes informative articles essays and studies across the entire scale of medical systems from large hospital programs to novel small-scale medical services. Education is an integral part of this amalgamation of sciences and selected articles are published in this area. Since existing medical systems are constantly being modified to fit particular circumstances and to solve specific problems the journal includes a special section devoted to status reports on current installations.