药物警戒与临床用药安全Pharmacovigilance320 : 741 ）23药物治疗错误的危害l 每100例非产科住院患者中发生6.5 次 ADEsADEs 中28 % 是可预防的。 l 致命性的、严重ADEs中，42 %是可预防的l 每例可预防的ADEs, 导致住院时间延长4.6天l 受调研单位因ADEs导致医药费增加达$ 560万元 Bates DW et al: The costs of adverse drug events in hospitalized patients. JAMA 1997 277: 307 24药 物 治 疗 错 误 的 危 害More Bad News About Medication Errors Dynamic Chiropractic, Sep 14, 2006 by Babcock, StephaneIOM Report: 1.5 Million Injured or Killed Annually . l According to the latest estimates from the Instituteof Medicine (IOM), l a staggering 1.5 million Americans are the victimsof medication errors every year, with approximately400,000 of those errors considered preventable. l The 2006 IOM estimates are distinctly higher thanprevious estimates that projected between 380,000 and 800,000 preventable adverse drug events occurring annually. 24药 物 治 疗 错 误 的 危 害More Bad News About Medication Errors Dynamic Chiropractic, Sep 14, 2006 by Babcock, Stephane美国医学研究院(IOM)报告: 每年致伤或致死150万人l美国每年因药物治疗错误导致伤害或死亡人数达150万人l药物治疗错误中约40万属可预防事件l2006 IOM 估计可预防药物不良事件明显高于以往报导的每年38万至80万ADEs24药物治疗错误的危害24More Bad News About Medication Errors Dynamic Chiropractic, Sep 14, 2006 by Babcock, Stephanel“The frequency of medication errors and preventablemedication related injuries represents a very seriouscause for concern“ l “The committee estimates that on average, a hospital patient is subject to at least one medication error perday . at least one quarter of all medication-relatedinjuries are preventable.“ l Those errors contribute directly to injury and/or death. 药物治疗错误的危害24More Bad News About Medication Errors Dynamic Chiropractic, Sep 14, 2006 by Babcock, Stephanel药物治疗错误和可预防的用药伤害的频发，是值得高度关注的问题l估计平均每一住院患者至少每遭遇一次用药错误，l药物所致伤害四分之一是可预防的药物治疗错误的危害24More Bad News About Medication Errors Dynamic Chiropractic, Sep 14, 2006 by Babcock, Stephanel Costs related to these incidents also have risen, with a conservative estimate of $3.5 billion spent annually, according to the 2006 report. l A 2004 analysis of billing information for 37 millionMedicare patients by HealthGrades, a health-care-quality company, estimated that 16 types of patientsafety errors resulted in an estimated $19 billion in extra costs and nearly 200,000 unnecessary deaths in hospitals across the U.S. between 2000 and 2002.5 药物治疗错误的危害24More Bad News About Medication Errors Dynamic Chiropractic, Sep 14, 2006 by Babcock, Stephane l 根据2006年报告：每年因用药错误所致ADEs造成的耗费保守估计35亿美元 l 根据2004年老年医疗保险370万病人的账务分析：2000-2002.5医院16种用药错误类型导致额外开支190亿美元并因事件导致20万例死亡药物治疗错误的危害24More Bad News About Medication Errors Dynamic Chiropractic, Sep 14, 2006 by Babcock, StephanelIn 2003, a study in the JAMA suggested that 27 percent of all adverse drug events experienced by Medicare patientsage 65 and older were preventable, and that “most“ wereattributable to doctor error. lIn terms of severity, nearly 40 percent of the events wereconsidered serious, life-threatening or fatal, 42.2 percent of which were deemed preventable. lThe study authors projected their data nationwide,estimating that in the elderly population, “there are in excess of 180,000 lifethreatening or fatal adversedrug events per year, of which more than 50 percent may be preventable,“ and adding that “these estimates are likely to be conservative.“ 药物治疗错误的危害24More Bad News About Medication ErrorsDynamic Chiropractic, Sep 14, 2006 by Babcock, Stephanel2003年, JAMA 研究报导：美国老年医疗保险患者(65岁以上) 所发生的ADEs 27%是可预防的, 且大多数源于医师的错误 l约40%是严重的致命性的 ADEs ，其中 42.2 %是可预防的 临床用药过程及相关人员临床用药过程 相关人员药物选择（selection） 医 师 药物采购（ procurement） 护 士 药物处方（ prescribing） 药 师 药物准备（ preparation） 患 者 药物调配（ dispensing） 药物使用（ administration） 临床用药监测（ monitoring）25药物治疗错误的表现（1）n 处方错误（医师责任）选药、剂量、剂型、用药途径或用法不当；重复处方，用药间隔时间不当。n 处方权限错误（医师责任）从无处方权人员获取处方n 药品配制错误（药师责任）剂型与处方不符；剂量与处方不符；质量不符（过期或降解）；重新配制不当。 26药物治疗错误的表现（2）n 药品使用方法错误（护士责任）未按预定时间用药（漏服）未按预定的间隔时间用药未按预定的方法用药（静注速度过快、肌注药误作静注）n 用药监测错误（医师、药师责任）肾毒性药物使用前后未作肾功能检测；慢性病患者加用药物时，未作药历复习造成不必要的药物相互作用；治疗窗窄小的药物，未作TDM 。27药物治疗错误的表现（3）n药物治疗过程的错误处方转抄错误（护士、医师、药师有责）:电子处方输入错误，手写处方辩别错误药品分发错误（药师有责）:因药名近似，包装相似，造成混淆。 用法说明不清导致患者不能理解（药师有责） 。n依从性错误（患者、药师责任）:患者不按医嘱用药，与药师指导不力有关。28药物治疗错误导致医疗事故实例n An elderly patient with rheumatoid arthritis diedafter receiving an overdose of methotrexate(甲氨喋呤) a 10 mg daily dose of the drug rather than the intended 10 mg weekly dose. n Some dosing mix-ups have occurred because daily dosing of methotrexate is typically used to treatpeople with cancer, while low weekly doses ofthe drug have been prescribed for other conditions, such as arthritis, asthma, and inflammatory boweldisease.29-剂量与用法错误药物治疗错误导致医疗事故实例n One patient died because 20 units of insulin (胰岛素)was abbreviated as “20 U,“ but the “U“ was mistaken for a “zero. “As a result, a dose of 200 unitsof insulin was accidentally injected.29-剂量与用法错误药物治疗错误导致医疗事故实例n A man died after his wife mistakenly applied six transdermal patches to hisskin at one time. nThe multiple patches delivered an overdose of the