重复服用酒石酸美托洛尔片用药差错1例
|
摘要
1例79岁女性因冠状动脉硬化性心脏病、高血压、高脂血症、席汉综合征、慢性肾功能不全、陈旧性脑梗塞、膀胱恶性肿瘤史、甲状腺功能减退,口服酒石酸美托洛尔片(25 mg,bid),非洛地平缓释片(5 mg,qd),托拉塞米片(20 mg,qd),左甲状腺素钠片(100μg,qd),复方α-酮酸片(2.52 g,tid),骨化三醇胶丸(0.25μg,bid)。入院第10天,因药品摆药机出现分装失误,护士核对过程中未及时发现,导致该患者早晨重复服用酒石酸美托洛尔片2片(50 mg)。当日测量患者心率74次/分,血压148/62 mmHg,与患者入院以来心率、血压相比未出现较大变化,继续观察患者心率、血压,并未出现异常。本次用药错误虽未造成明显伤害,但造成错误的原因与医务人员对自动化仪器过于信赖而忽视人工作用的重要性有关,通过总结产生本次错误的原因与预防措施,以引起医务人员重视,避免今后类似错误的发生。
A 79-year-old woman was given metoprolol tartrate tablets(25 mg, bid), felodipine sustainedrelease tablets(5 mg, qd), torasemide tablets(20 mg, qd), levothyroxine sodium tablets(100 μg, qd), compound α-ketoacid tablets(2.52 g, tid) and calcitriol capsules(0.25 μg, bid) orally because of coronary heart disease, hypertension, hyperlipidemia, Sheehan syndrome, chronic renal insufficiency, old cerebral infarction, bladder cancer history and hypothyroidism. On the 10 th day of admission, due to the dispensing error of the medicine dispensing machine, the nurse failed to find it in time during the checking process, resulting in the patient taking 2 tablets(50 mg) of metoprolol tartrate in the morning. The heart rate and blood pressure of the patient were measured to be 74 times/minute and 148/62 mmHg on the same day. Compared with the heart rate and blood pressure of the patient since admission, there was no significant change. The heart rate and blood pressure of the patient were observed sequentially, and no abnormality was found. Although this drug use error did not cause obvious harm, the cause of the error was related to the medical staff's over-reliance on automated instruments and the neglect of the importance of artificial effects. The causes of this error and preventive measures were summarized in order to attract the attention of medical staff to avoid similar errors in the future.
A 79-year-old woman was given metoprolol tartrate tablets(25 mg, bid), felodipine sustainedrelease tablets(5 mg, qd), torasemide tablets(20 mg, qd), levothyroxine sodium tablets(100 μg, qd), compound α-ketoacid tablets(2.52 g, tid) and calcitriol capsules(0.25 μg, bid) orally because of coronary heart disease, hypertension, hyperlipidemia, Sheehan syndrome, chronic renal insufficiency, old cerebral infarction, bladder cancer history and hypothyroidism. On the 10 th day of admission, due to the dispensing error of the medicine dispensing machine, the nurse failed to find it in time during the checking process, resulting in the patient taking 2 tablets(50 mg) of metoprolol tartrate in the morning. The heart rate and blood pressure of the patient were measured to be 74 times/minute and 148/62 mmHg on the same day. Compared with the heart rate and blood pressure of the patient since admission, there was no significant change. The heart rate and blood pressure of the patient were observed sequentially, and no abnormality was found. Although this drug use error did not cause obvious harm, the cause of the error was related to the medical staff's over-reliance on automated instruments and the neglect of the importance of artificial effects. The causes of this error and preventive measures were summarized in order to attract the attention of medical staff to avoid similar errors in the future.
引文
[1]Kruer RM,Jarrell AS,Latif A.Reducing medication errors in critical care:a multimodal approach[J].Clin Pharmacol,2014,(6):117-126
[2]Ferner RE,Aronson JK.Medication errors,worse than a crime[J].Lancet,2000,355(9208):947-948
[3]朱岫芳.美托洛尔致不良反应47例Meta分析[J].中国老年学杂志,2013,33(23):6019-6020
[4]刘晓琦,劳海燕,张建萍,等.美托洛尔基于循证的药物评价[J].中国执业药师,2013,10(5):32-36
[5]张亚松,张培,王宇.鱼骨图分析法用于医院药学部人力资源管理实践[J].中国药业,2015,24(22):143-144
[6]周国秀,成孝林.临床护理人员用药风险防范认知度调查分析[J].护理实践与研究,2012,9(21):148-150
[7]孙慧清,邵士川.药物不良事件危害与分析[J].社区医学杂志,2006,4(8):26-27
[8]合理用药国际网络中国中心组临床安全用药组,中国药理学会药源性疾病学专业委员会,中国药学会医院药学专业委员会,等.中国用药错误管理专家共识[J].药物不良反应杂志,2014,16(6):321-326
[9]梁海涛,施孝金,钟明廉.用药错误及其预防[J].上海医药,2011,32(4):161-163
[2]Ferner RE,Aronson JK.Medication errors,worse than a crime[J].Lancet,2000,355(9208):947-948
[3]朱岫芳.美托洛尔致不良反应47例Meta分析[J].中国老年学杂志,2013,33(23):6019-6020
[4]刘晓琦,劳海燕,张建萍,等.美托洛尔基于循证的药物评价[J].中国执业药师,2013,10(5):32-36
[5]张亚松,张培,王宇.鱼骨图分析法用于医院药学部人力资源管理实践[J].中国药业,2015,24(22):143-144
[6]周国秀,成孝林.临床护理人员用药风险防范认知度调查分析[J].护理实践与研究,2012,9(21):148-150
[7]孙慧清,邵士川.药物不良事件危害与分析[J].社区医学杂志,2006,4(8):26-27
[8]合理用药国际网络中国中心组临床安全用药组,中国药理学会药源性疾病学专业委员会,中国药学会医院药学专业委员会,等.中国用药错误管理专家共识[J].药物不良反应杂志,2014,16(6):321-326
[9]梁海涛,施孝金,钟明廉.用药错误及其预防[J].上海医药,2011,32(4):161-163