老年患者亚胺培南西司他丁钠用药错误报告分析及防范建议

Analysis of imipenem and cilastatin sodium medication error reports and prevention suggestions in elderly patients

目的分析老年患者(≥60岁)亚胺培南西司他丁钠用药错误(ME)报告,并提出针对性的防范建议。方法收集2012年9月22日至2022年9月22日全国临床安全用药监测网中有关老年患者亚胺培南西司他丁钠的ME报告,对ME的分级、内容、错误引发人员、发生场所、发现人员和引发因素等进行分析。结果共收集老年患者亚胺培南西司他丁ME报告158例,其中2例(1.27%)为严重ME,包括1例肾功能不全患者因未调整亚胺培南西司他丁钠剂量而导致肾功能损害,1例脑外伤并发癫痫患者因肺炎使用亚胺培南西司他丁钠再次诱发癫痫。ME排名前3位的为溶媒、用量和品种选择;ME引发人员主要为医师(130例,82.28%)和药师(17例,10.76%);ME发现人员主要为药师(133例,84.18%);ME引发因素多为人员因素,主要由知识欠缺和(或)培训不足引起。结论老年患者使用亚胺培南西司他丁钠时需重点关注处方和调配环节的ME,尤其是肾功能不全患者需调整剂量,癫痫患者慎用。应加强信息化建设以减少处方环节的ME,统一规格及用法用量,同时加强医务人员合理用药培训。

Objective To analyze medication error(ME)reports involving imipenem and cilastatin sodium in elderly patients(≥60 years old)and to propose targeted prevention suggestions.Methods ME reports concerning imipenem and cilastatin sodium in elderly patients were extracted from the National Monitoring Network for Clinical Safe Drug Medication between September 22,2012 and September 22,2022.The severity of errors,content of errors,personnel involved in the errors,location of occurrence,discoverers of the errors,and contributing factors were retrospectively analyzed.Results A total of 158 ME reports were extracted.As for the severe MEs(2 cases,1.27%),1 patient with renal insufficiency experienced further kidney damage due to non-adjustment of dosage.The other patient had epilepsy due to brain injury and developed seizures after using imipenem and cilastatin sodium.The first three MEs were menstruum,dosage and variety.MEs were mainly triggered by physicians(130 cases,82.28%)and pharmacists(17 cases,10.76%).133 cases(84.18%)of errors were identified by pharmacists.The main causes of ME were personnel factors,most of MEs were due to lack of knowledge and(or)insufficient training.Conclusion Special attention should be given to prescription and dispensing errors when administering imipenem and cilastatin sodium to elderly patients,especially regarding dosage adjustments in patients with renal impairment,cautious use in patients with epilepsy.It is recommended that information construction should be fortified to reduce prescription errors,and specifications and dosage instructions should standardized.At the same time,training for medical staff in the rational use of drugs should be strengthened.