L’errore nella somministrazione di terapia farmacologica endovenosa nelle Unità di Terapia Intensiva: stato dell’arte e strategie

Daniele Donati, Daniela Tartaglini, Marco Di Muzio

Abstract

Questa tipologia di errore emerge con maggior frequenza nelle UTI per alcune caratteristiche proprie del contesto come: criticità dei pazienti, elevata quantità di farmaci somministrati via endovenosa, necessità di risolvere specifici calcoli per garantire dosi ottimali, frequenti variazioni delle prescrizioni, continui aggiornamenti delle velocità infusionali, potenziali incompatibilità tra i farmaci infusi, necessità di gestire un’elevata quantità di informazioni in situazioni di urgenza.

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Riferimenti bibliografici

National Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy of Sciences; 1999.

The Joint Commission. Preventing pedi- atric medication errors. Sentinel Event Alert. 39. http://www.jointcommission. org/sentinelevents/sentineleventalert/ sea_39.htm. Published 2008. Accessed May 4, 2009.

National Coordinating Council for Med- ication Error Reporting and Prevention. National Coordinating Council for Med- ication Error. Reporting and Prevention in human services taxonomy of medica- tion errors. http://www.nccmerp.org/pdf/ taxo2001-07-31.pdf. Published 2013. Accessed May 23, 2013.

CAmiré e, moyeN e, StelFox HT. Medication errors in critical care: risk factors, preven- tion and disclosure. Can Med Assoc J. 2009; 180(9):936-943.

KrAheNBuhl-melCher A, SChlieNGer r, lAmPert m, hASChKe m, dreWe J, KrAheNBuhl S. Drug-related problems in hospitals: a re- view of the recent literature. Drug Saf. 2007; 30(5):379-407.

Prot S, FoNtAN Je, AlBerti C, BourdoN o, FAr- Noux C, mACher MA, Foureau A, et al. Drug administration errors and their determi- nants in pediatric in-patients. Int J Qual Health Care. 2005; 17:381-389.

BoWdle TA. Drug administration errors from the ASA closed claims project. ASA Newsletter. 2004; 67(6):11-13.

KANe-Gill SL, JACoBi J, rothSChild Jm. Adverse drug events in intensive care units: risk factors, impact, and the role of team care. Crit Care Med. 2010; 38(6):S83-S89.

CulleN dJ, SWeitzer BJ, BAteS dW, BurdiCK e, edmoNdSoN A, leAPe LL. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med. 1997; 25(8):1289-1297.

WAlSh t, BeAtty PC. Human factors error and patient monitoring. Physiol Meas. 2002; 23(3):R111-R132.

moyeN e, CAmire e, StelFox HT. Clinical re- view: medication errors in critical care. Crit Care. 2008; 12(2):208.

ArmitAGe G, KNAPmAN H. Adverse events in drug administration: a literature review. J Nurs Manage. 2003; 11(2):130-140.

Frith KH. Medication Errors in the Inten- sive Care Unit. Literature Review Using the SEIPS Model. AACN Advanced Critical Care. 2013; 24(4):389-404.

Bohomol e, rAmoS lh, d’iNNoCeNzo M. Med- ication errors in an intensive care unit. J AdvNurs. 2009; 65(6):1259-1267.

BeNKirANe rr,ABouqAl r,hAimeur CC,et al.In- cidence of adverse drug events and me- dication errors in intensive care units: a prospective multicenter study. J Patient Saf. 2009; 5(1):16-22.

Berdot S, SABAtier B, GillAizeAu F, CAruBA t, Pro- GNoN P, durieux P. Evaluation of drug ad- ministration errors in a teaching hospital. BMC Health Serv Res. 2012; 12:60.

Wilmer A, louie K, dodeK P, WoNG h, AyAS N. Incidence of medication errors and ad- verse drug events in the ICU: a systema- tic review. QualSaf Health Care. 2010; 19(5):e7.

PAtriCiAN PA, BroSCh LR. Medication error reporting and the work environment in a military setting. J Nurs Care Qual. 2009; 24(4):277-286.

FlyNN eA, BArKer KN, PePPer GA, BAteS dW, miKeAl RL. Comparison of methods for de- tecting medication errors in 36 hospitals and skilled-nursing facilities. AM J He- alt-Syst Pharm. 2002; 59(5):436-446.

VAleNtiN A, CAPuzzo m, Guidet B, moreNo r, metNitz B, BAuer P, metNitz P. Errors in admi- nistration of parenteral drugs in intensive care units: multinational prospective stu- dy. BMJ. 2009; 338:b814.

KieKKAS P, KArGA m, lemoNidou C, ArethA d, KArANiKolAS M. Medication errors in criti- cally ill adults: a review of direct obser- vation evidence. Am J Crit Care. 2011; 20(1):36-44.

FAhimi F, AriAPANAh P, FAizi m, ShAFAqhi B, NAm- dAr r, ArdAKANi MT. Errors in preparation and administration of intravenous med- ications in the intensive care unit of a teaching hospital: an observational study. Aust Crit Care. 2008; 21(2):110-116.

CArAyoN P, SChooFS huNdt A, KArSh Bt, et al. Work system design for patient safety: the SEIPS model. Qual Safety Health Care. 2006; 15:i50–i58.

doNABediAN A. Evaluating the quality of medical care... reprinted from The Mil- bank Memorial Fund Quarterly, Vol. 44, No. 3, Pt. 2, 1966 (pp. 166-203). Milbank Q. 2005; 83(4):691-729.

PezzoleSi C, GhAleB m, KoStrzeWSKi A, dhilloN S. Is mindful re ective practice the way for- ward to reduce medication errors? [pub- lished online ahead of print April 12, 2013]. Int J Pharm Pract.DOI:10.1111/ijpp.12031.

mAttox EA. Strategies for improving pa- tient safety: linking task type to error type. Crit Care Nurse. 2012; 32(1):52–78.

GAlANtiNo ml, BAime m, mAGuire m, SzAPAry Po, FArrAr JT. Association of psychologi- cal and physiological measures of stress in health-care professionals during an 8-week mindfulness meditation program: mindfulness in practice. Stress Health J Int Soc Invest Stress. 2005; 21(4):255– 261.

mANiAS e, WilliAmS A, lieW D. Interventions to reduce medication errors in adult inten- sive care: a systematic review. Br J Clin- Pharmacol. 2012; 74(3):411-423.

ABBASiNAzAri m, zAreh-torANPoShti S, hASSA- Ni A, SiStANizAd m, AziziAN h, PANAhi Y. The ef- fect of information provision on reduction of errors in intravenous drug preparation and administration by nurses in ICU and surgical wards. Acta Med Iran. 2012; 50(11):771-777.

lu m-C, yu S, CheN iJ, WANG K-WK, Wu h-F,

tANG F-i. Nurses’ knowledge of high-alert medications: a randomized controlled.

trial. Nurse Educ Today. 2013; 33(1):24-30.

ABStoSS Km, ShAW Be, oWeNS tA, JuNo Jl, CommiSKey el, NiedNer MF. Increasing me- dication error reporting rates while redu- cing harm through simultaneous cultural and system-level interventions in an in- tensive care unit. BMJ Qual Safety. 2011; 20(11):914-922.

mArK BA, huGheS lC, BelyeA m, BACoN Ct, ChANG y, JoNeS CA. Exploring organizatio- nal context and structure as predictors of medication errors and patient falls. J Pa- tient Safety. 2008; 4(2):66-77.

rAFtoPouloS V, PAVlAKiS A. Safety climate in 5 intensive care units: a nationwide ho- spital survey using the Greek-Cypriot ver- sion of the Safety Attitudes Questionnai- re. J Crit Care. 2013; 28(1):51-61.

VAleNtiN A, SChiFFiNGer m, Steyrer J, huBer C, StruNK G. Safety climate reduces medi- cation and dislodgement errors in routi- ne intensive care practice. Intensive Care Med. 2013; 39(3):391-398.

rothSChild Jm, hurley AC, lANdriGAN CP, et al. Recovery from medical errors: the critical care nursing safety net. Jt Comm J Qual Patient Saf. 2006; 32(2):3-72.

GABel SPeroNi K, FiSher J, deNNiS m, dANiel M. Research Corner. What causes near-mis- ses and how are they mitigated? Nurs (Lond.). 2013; 43(4):19-24.

elGANzouri eS, StANdiSh CA, ANdroWiCh I. Me- dication administration time study (MA- TS) nursing staff performance of medi- cation administration. J Nurs Adm. 2009; 39(5):204-210.

PAleSe A, SArtor A, CoStAPerAriA G, BreSAdo- lA V. Interruptions during nurses’ drug rounds in surgical wards: observational study. J NursManag. 2009; 17(2):185–192.

CArAyoN P, WetterNeCK tB, huNdt AS, et al. Evaluation of nurse interaction with bar code medication administration techno- logy in the work environment. J Patient Safety. 2007; 3(1):34-42.

holdeN rJ, SCANloN mC, PAtel Nr, et al. A hu- man factors framework and study of the effect of nursing workload on patient sa- fety and employee quality of working life. BMJ Qual Safety. 2011; 20(1):15-24.

ANthoNy K, WieNCeK C, BAuer C, dAly B, AN- thoNy MK. No interruptions please: impact of a No Interruption Zone on medication safety in intensive care units. Crit Care Nurse. 2010; 30(3):21-29.

tomietto m, SArtor A, mAzzoColi e, PAleSe A. Paradoxical effects of a hospital-based, multi-intervention programme aimed at reducing medication round interruptions. J NursManag. 2012; 20(3):335-343.

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