老年人头孢哌酮舒巴坦用药错误报告分析与建议

Cefoperazone/sulbactam-related medication errors in the elderly and countermeasures

目的探讨老年人(≥60岁)头孢哌酮舒巴坦用药错误(ME)发生情况及影响因素,制定针对性的防范建议。方法收集全国临床安全用药监测网2012年9月22日至2021年9月22日期间老年人头孢哌酮舒巴坦ME报告,对ME的错误分级、错误内容、错误引发人员、错误发生场所、错误发现人员和错误因素等进行分析。结果老年人头孢哌酮舒巴坦ME报告共计210例,男143例、女67例,中位年龄73(60~97)岁;B级(轻型ME)错误最多,139例(66.19%);严重ME 10例(4.76%):4例肝功能(肝酶或胆红素)严重异常使用头孢哌酮舒巴坦后肝功能进一步恶化;2例凝血高危因素患者用药后没有及时监测凝血功能导致凝血酶原时间(PT)延长且有1例出现上消化道出血,2例患者出现出血事件后未及时停药导致PT持续延长;1例患者使用后出现肾功能不全后没有进行相应的剂量调整导致严重肾功能不全,1例过敏性休克患者救治没有选择首选的肾上腺素。错误引发人员主要是医生,140例(66.67%),错误内容前3位为用量(肾功能不全患者剂量没有进行相应调整)、频次(每日1次给药)以及品种(肝功能严重受损患者及有出血高危因素患者选用头孢哌酮舒巴坦),还需关注医生引发的相互作用错误(联用含有乙醇的药品);引发因素主要是知识欠缺/培训不足、疲劳。错误引发人员其次是药师,51例(24.29%),错误内容主要为品种错误;主要引发因素是药名相似/外观相似(LASA)。错误发现人员主要是药师,152例(72.38%)。结论老年人头孢哌酮舒巴坦严重ME占比高于全国临床安全用药严重ME占比;重点需要关注处方和调配环节用药错误;重点需要关注肝肾功能不全患者品种选择和剂量调整、凝血功能监测和避免联用含有乙醇辅料的药品。强化信息建设减少处方环节的ME,重视药品遴选和增加药品货位LASA提示标签以减少LASA药品调配错误,同时需要加强医务人员合理用药培训,制定过敏性休克抢救流程。

Objective To investigate the incidence and causes of medication errors(ME)related to cefoperazone/sulbactam in the elderly(≥60 years old)so as to provide data for targeted precautions.Methods Reports about cefoperazone/sulbactam-related ME in the elderly were retrieved from the National Monitoring Network for Clinical Safe Drug Medication between September 22,2012 and September 22,2021.The severity of errors,content of errors,locations of errors,the person(s)responsible,and causes of errors were retrospectively analyzed.Results A total of 210 ME reports were retrieved,involving 143 males and 67 females,with a median age of 73(60 to 97).In terms of severity of errors,errors of Class B(Minor ME)were dominating(139 cases,66.19%).There were 10 cases of severe ME(4.76%):4 patients with severe liver insufficiency were prescribed with cefoperazone/sulbactam,which aggravated their liver function,2 patients at a high risk of bleeding had not had their blood coagulation indexes monitored,resulting in prolonged prothrombintime(PT),and one of them even suffered upper gastrointestinal tract bleeding,2 patients with bleeding events did not discontinue medication immediately,which prolonged their PT,1 patient presented with renal insufficiency after using cefoperazone/sulbactam,but did not stop medication immediately,resulting in severe renal insufficiency,and 1 patient with anaphylactic shock did not choose to use epinephrine first.Among these 213 ME,140(24.29%)were made by physicians.The top three types of errors were related to the dosage,frequency(qd)and variety.Most of these ME were due to a lack of knowledge or training and fatigue.ME made by pharmacists(51 cases,24.29%)were mainly related to the variety(LASA drugs).One hundred and fifty-two(72.38%)of these errors were spotted by pharmacists.Conclusion The proportion of severe ME concerning cefoperazone/sulbactam is higher than that of severe ME related to clinical drugs across the country.Errors associated with prescriptions and dispensing merit attention.Importance should be attached to the selection of the right drug variety,quick dose adjustment,monitoring of coagulation disorders and to prevention of combined use of drugs containing ethanol excipients in patients with hepatorenal insufficiency.It is recommended that information be made more accessible to reduce the ME related to prescriptions,drug selection be taken seriously,labels of LASA drugs be made more eye-catching to lower the risk of LASA errors.Clinicians ought to be better informed of rational drug use,and rescue processes for anaphylactic shock have to be formulated.