Analysis on reports of medication errors on proton pump inhibitors in National Monitoring Network for Clinical Safe Medication in 2020
10.3760/cma.j.cn114015-20220321-00228
- VernacularTitle:全国临床安全用药监测网2020年质子泵抑制剂用药错误报告分析
- Author:
Yujie QIU
1
;
Yuqin WANG
1
;
Qingxia ZHANG
1
Author Information
1. 首都医科大学宣武医院药学部，国家老年疾病临床医学研究中心，北京 100053
- Publication Type:Journal Article
- Keywords:
Proton pump inhibitors;
Medication errors;
Safety management
- From:
Adverse Drug Reactions Journal
2022;24(9):454-461
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To analyze the occurrence of medication errors (MEs) and their influencing factors on proton pump inhibitors (PPIs) and to provide reference for the standard use of PPIs in clinic.Methods:The ME reports on PPI-related MEs in the National Monitoring Network for Clinical Safe Medication (monitoring network) from January 1, 2020 to December 31, 2020, were collected and information of MEs including drugs involved, ME grading, error content, the persons who triggered and found the errors, and the factors that caused the errors were analyzed.Results:A total of 593 PPI-related ME reports from 97 hospitals in 21 provinces and municipalities in China were collected in the monitoring network in 2020. A total of 593 patients were involved, including 358 males (60.4%) and 235 females (39.6%), aged from 1 to 99 years old with an average age of 53.7 years. In the 593 MEs, there were 418 (70.5%), 167 (28.2%), 7 (1.2%), and 1 (0.2%) MEs were graded as grade B, C, D, and E, respectively; a total of 6 kinds of PPIs were involved and 649 times of ME occurred, of which 177 times (27.2%) were related to omeprazole, 143 (22.0%) to rabeprazole, 135 (20.8%) to esomeprazole, 123 (19.0%) to pantoprazole, 66 (10.2%) to lansoprazole, and 5 (0.8%) to ilaprazole. Among the 593 patients, the medication indications for PPIs included prevention of stress mucosal injury in 303 patients (51.1%), gastroesophageal reflux disease in 91 patients (15.3%), peptic ulcer in 64 patients (10.8%), upper gastrointestinal bleeding in 25 patients (4.2%), helicobacter pylori infection eradication in 6 patients (1.0%), and non-steroidal anti-inflammatory drug-related ulcers in 6 patients (1.0%). There were 103 patients (17.4%) received PPIs without appropriate indications and 5 patients (0.8%) with 2 indications at the same time. The 593 ME reports involved a total of 609 times of ME content, and the wrong indication (16.9%, 103/609) ranked the first, followed by the wrong drug class (16.3%, 99/609) and the wrong medication frequency (14.0%, 85/609). Among the 593 MEs, 75.1% (445 MEs) were triggered by physician, 20.7% (123 MEs) by pharmacists, 2.5% (15 MEs) by nurse, 0.7% (4 MEs) by patients/family members, and 1.0% (6 MEs) by others; 418 MEs (70.5%) were detected and intercepted in time, of which 87.6% (366/418) were found by pharmacists, 8.1% (34/418) by nurses, and 4.3% (18/418) by patients/family members. The factors that caused MEs occurred 659 times in total, mainly including lack of knowledge/insufficient training (accounting for 50.8%, 335/659), fatigue (accounting for 18.4%, 121/659), and look alike/sound alike (accounting for 9.1%, 60/659). Conclusions:The contents of PPIs-related MEs mainly include wrong indications, wrong drug class, and wrong medication frequency. MEs are mainly caused by physicians and mostly discovered and intercepted by pharmacists. Lack of knowledge/inadequate training is a major factor in causing MEs.
