ความคลาดเคลื่อนทางยาในเด็กและแนวทางการป้องกัน
DOI:
https://doi.org/10.69598/tbps.14.2.105-118คำสำคัญ:
ความคลาดเคลื่อนทางยา, ผู้ป่วยเด็ก, การป้องกันบทคัดย่อ
การเกิดความคลาดเคลื่อนทางยาในเด็ก มีโอกาสก่อให้เกิดอันตรายที่รุนแรงกว่าผู้ใหญ่ถึง 3 เท่า โดยความคลาดเคลื่อนที่พบบ่อยที่สุดคือ การได้รับยาผิดขนาดยาต่อวัน เนื่องจากผู้ป่วยเด็กมีปัจจัยเรื่องการเจริญเติบโตทางสรีรวิทยาซึ่งมีผลต่อขนาดยาที่ใช้ในการรักษา ดังนั้นแพทย์ต้องคำนวณขนาดยาในผู้ป่วยเด็กแต่ละราย อาจทำให้เกิดการคำนวณขนาดยาที่ผิดพลาดได้ นอกจากนี้ยังมีปัจจัยอื่น ๆ เช่น การไม่มีรูปแบบของยาที่เหมาะสมสำหรับผู้ป่วยเด็ก การขาดประสบการณ์ในการตรวจผู้ป่วยเด็ก การบันทึกรายการยาในระบบคอมพิวเตอร์โดยบุคคลกรอื่นที่ไม่ใช่แพทย์ผู้สั่งใช้ยา และ วิธีบริหารยาที่มีความละเอียดถึงระดับจุดทศนิยม ล้วนเป็นปัจจัยสำคัญที่ทำให้เกิดความคลาดเคลื่อนทางยาในเด็ก แนวทางการป้องกันเพื่อลดความคลาดเคลื่อนที่จะเกิดขึ้น ได้แก่ การนำระบบบันทึกใบสั่งยาโดยแพทย์ที่มีระบบช่วยแพทย์ในการตัดสินใจเรื่องคำสั่งการรักษามาใช้ การปรับเปลี่ยนพฤติกรรมการสั่งยาของแพทย์ การเตรียมยารูปแบบเฉพาะสำหรับผู้ป่วยเด็ก การนำเครื่องจัดยาอัตโนมัติมาใช้ในการจัดยา การมีเภสัชกรประจำหอผู้ป่วยเด็ก การนำระบบบาร์โค้ด และเทคโนโลยีใหม่ ๆ มาใช้ในการบริหารยาของพยาบาล และ การสื่อสารวิธีบริหารยากับผู้ปกครอง ในอนาคตคาดว่าจะมีการนำเทคโนโลยีใหม่ ๆ มาใช้เพื่อเพิ่มความปลอดภัยในการรักษาผู้ป่วยเด็กมากขึ้น ดังนั้นการสนับสนุนในเชิงนโยบายจากระบบสาธารณสุขและโรงพยาบาล จึงมีความสำคัญ
เอกสารอ้างอิง
1. World Health Organization. Medication errors: technical series on safer primary care. Geneva: WHO; 2016.
2. Wong IC, Wong LY, Cranswick NE. Minimising medication errors in children. Arch Dis Child. 2009;94(2):161-4.
3. Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care. 2002;11(4):340-4.
4. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-20.
5. World Health Organization. Promoting safety of medicines for children. Geneva: WHO; 2006.
6. Goedecke T, Ord K, Newbould V, Brosch S, Arlett P. Medication errors: new EU good practice guide on risk minimisation and error prevention. Drug Saf. 2016;39(6):491-500.
7. Wu A. Minimizing Medication Errors in Pediatric Patients. US Pharm. 2019;44(4):20-2.
8. Ningsanon T, Chulavatnatol S, Montakantikul P, editors. Medication error prevention for patient safety. Bangkok: The Association of Hospital Pharmacy (Thailand); 2004. (In Thai)
9. Reason J. Human error: models and management. BMJ. 2000;320(7237):768-70.
10. Pharmacy Department. Development and Data Management Division. In: Faculty of Medicine Siriraj Hospital. Annual report 2017. Bangkok: The Faculty; 2017. p.304-7. (in Thai)
11. Glanzmann C, Frey B, Meier CR, Vonbach P. Analysis of medication prescribing errors in critically ill children. Eur J Pediatr. 2015;174:1347-55.
12. Manias E, Kinney S, Cranswick N, Williams A. Medication errors in hospitalised children. J Paediatr Child Health. 2014;50:71-7.
13. Leahy IC, Lavoie M, Zurakowski D, Baier AW, Brustowicz RM. Medication errors in a pediatric anesthesia setting: incidence, etiologies, and error reduction strategies. J Clin Anesth. 2018;49:107-11.
14. Koren G, Barzilay Z, Greenwald M. Tenfold errors in administration of drug doses: a neglected iatrogenic disease in pediatrics. Pediatrics. 1986;77(6):848-9.
15. Koren G, Haslam RH. Pediatric medication errors: predicting and preventing tenfold disasters. J Clin Pharmacol. 1994;34:1043-5.
16. Rowe C, Koren T, Koren G. Errors by paediatric residents in calculating drug doses. Arch Dis Child. 1998;79(1):56-8.
17. Glover ML, Sussmane JB. Assessing pediatrics residents' mathematical skills for prescribing medication: a need for improved training. Acad Med. 2002;77(10):1007-10.
18. Gladstone J. Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. J Adv Nurs. 1995;22:628-37.
19. Kozer E, Scolnik D, Keays T, Shi K, Luk T, Koren G. Large Errors in the Dosing of Medications for Children. N Engl J Med. 2002;346(15):1175-6.
20. Ivanovska V, Rademaker CM, van Dijk L, Mantel-Teeuwisse AK. Pediatric drug formulations: a review of challenges and progress. Pediatrics.
2014;134(2):361-72.
21. Raksamani K. Teaching non - Technical Skills in Anesthesiology. The Thai Journal of Anesthesiology. 2015;41(1):47-52. (In Thai)
22. Grout JR. Mistake proofing: changing designs to reduce error. Qual Saf Health Care. 2006;15(suppl 1):i44-i9.
23. Johnson KB, Butta JK, Donohue PK, Glenn DJ, Holtzman NA. Discharging patients with prescriptions instead of medications: sequelae in a teaching hospital. Pediatrics. 1996;97(4):481-5.
24. Raju TN, Kecskes S, Thornton JP, Perry M, Feldman S. Medication errors in neonatal and paediatric intensive-care units. Lancet. 1989;2:374-6.
25. Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83(6):492-7.
26. Taylor JA, Brownstein D, Christakis DA, Blackburn S, Strandjord TP, Klein EJ, et al. Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics. 2004;114(3):729-35.
27. Stebbing C, Wong ICK, Kaushal R, Jaffe A. The role of communication in paediatric drug safety. Arch Dis Child. 2007;92(5):440-5.
28. Kahn S, Abramson EL. What is new in paediatric medication safety? Arch Dis Child. 2019;104(6):596-9.
29. Mullett CJ, Evans RS, Christenson JC, Dean JM. Development and impact of a computerized pediatric antiinfective decision support program. Pediatrics. 2001;108(4):E75.
30. Lehmann CU, Conner KG, Cox JM. Preventing provider errors: online total parenteral nutrition calculator. Pediatrics. 2004;113(4):748-53.
31. Potts AL, Barr FE, Gregory DF, Wright L, Patel NR. Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics. 2004;113(1):59-63.
32. King WJ, Paice N, Rangrej J, Forestell GJ, Swartz R. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;112(3):506-9.
33. Sethuraman U, Kannikeswaran N, Murray KP, Zidan MA, Chamberlain JM. Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department. Acad Emerg Med. 2015;22(6):714-9.
34. Walsh KE, Kaushal R, Chessare JB. How to avoid paediatric medication errors: a user's guide to the literature. Arch Dis Child. 2005;90(7):698-702.
35. Zorc JJ, Hoffman JM, Harper MB. IT in the ED: a new section of pediatric emergency care. Pediatr Emerg Care. 2012;28(12):1399-401.
36. Chaparro JD, Classen DC, Danforth M, Stockwell DC, Longhurst CA. National trends in safety performance of electronic health record systems in children’s hospitals. J Am Med Inform Assoc. 2017;24(2):268-74.
37. Stucky ER; American Academy of Pediatrics Committee on Drugs; Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 2003;112(2):431-6.
38. Conroy S, North C, Fox T, Haines L, Planner C, Erskine P, et al. Educational interventions to reduce prescribing errors. Arch Dis Child. 2008;93(4):313-5.
39. Siebert JN, Ehrler F, Combescure C, Lacroix L, Haddad K, Sanchez O, et al. A mobile device app to reduce time to drug delivery and medication errors during simulated pediatric cardiopulmonary resuscitation: a randomized controlled trial. J Med Internet Res. 2017;19(2):e31.
40. Miller MR, Takata G, Stucky ER, Neuspiel DR; American Academy of Pediatrics Steering Committee on Quality Improvement and Management; Committee on Hospital Care. Principles of pediatric patient safety: reducing harm due to medical care. Pediatrics. 2011;127(6):1199-210.
41. Fortescue EB, Kaushal R, Landrigan CP, McKenna KJ, Clapp MD, Federico F, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;111(4):722-9.
42. Rosenfeld E, Kinney S, Weiner C, Newall F, Williams A, Cranswick N, et al. Interdisciplinary medication decision making by pharmacists in pediatric hospital settings: an ethnographic study. Res Social Adm Pharm. 2018;14:269-78.
43. Nunn AJ. Making medicines that children can take. Arch Dis Child. 2003;88(5):369-71.
44. Roark DC. Bar codes and drug administration: can new technology reduce the number of medication errors? Am J Nurs. 2004;104(1):63-6.
45. American Society of Health-System Pharmacists. ASHP guidelines on the safe use of automated dispensing devices. Am J Health Syst Pharm. 2010;67:483-90.
46. Schwarz HO, Brodowy BA. Implementation and evaluation of an automated dispensing system. Am J Health Syst Pharm. 1995;52:823-8.
47. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication accurately. Pediatrics. 1997;100(3):330-3.
48. Wong ICK, Basra N, Yeung VW, Cope J. Supply problems of unlicensed and off-label medicines after discharge. Arch Dis Child. 2006;91(8):686-8.
2. Wong IC, Wong LY, Cranswick NE. Minimising medication errors in children. Arch Dis Child. 2009;94(2):161-4.
3. Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care. 2002;11(4):340-4.
4. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-20.
5. World Health Organization. Promoting safety of medicines for children. Geneva: WHO; 2006.
6. Goedecke T, Ord K, Newbould V, Brosch S, Arlett P. Medication errors: new EU good practice guide on risk minimisation and error prevention. Drug Saf. 2016;39(6):491-500.
7. Wu A. Minimizing Medication Errors in Pediatric Patients. US Pharm. 2019;44(4):20-2.
8. Ningsanon T, Chulavatnatol S, Montakantikul P, editors. Medication error prevention for patient safety. Bangkok: The Association of Hospital Pharmacy (Thailand); 2004. (In Thai)
9. Reason J. Human error: models and management. BMJ. 2000;320(7237):768-70.
10. Pharmacy Department. Development and Data Management Division. In: Faculty of Medicine Siriraj Hospital. Annual report 2017. Bangkok: The Faculty; 2017. p.304-7. (in Thai)
11. Glanzmann C, Frey B, Meier CR, Vonbach P. Analysis of medication prescribing errors in critically ill children. Eur J Pediatr. 2015;174:1347-55.
12. Manias E, Kinney S, Cranswick N, Williams A. Medication errors in hospitalised children. J Paediatr Child Health. 2014;50:71-7.
13. Leahy IC, Lavoie M, Zurakowski D, Baier AW, Brustowicz RM. Medication errors in a pediatric anesthesia setting: incidence, etiologies, and error reduction strategies. J Clin Anesth. 2018;49:107-11.
14. Koren G, Barzilay Z, Greenwald M. Tenfold errors in administration of drug doses: a neglected iatrogenic disease in pediatrics. Pediatrics. 1986;77(6):848-9.
15. Koren G, Haslam RH. Pediatric medication errors: predicting and preventing tenfold disasters. J Clin Pharmacol. 1994;34:1043-5.
16. Rowe C, Koren T, Koren G. Errors by paediatric residents in calculating drug doses. Arch Dis Child. 1998;79(1):56-8.
17. Glover ML, Sussmane JB. Assessing pediatrics residents' mathematical skills for prescribing medication: a need for improved training. Acad Med. 2002;77(10):1007-10.
18. Gladstone J. Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. J Adv Nurs. 1995;22:628-37.
19. Kozer E, Scolnik D, Keays T, Shi K, Luk T, Koren G. Large Errors in the Dosing of Medications for Children. N Engl J Med. 2002;346(15):1175-6.
20. Ivanovska V, Rademaker CM, van Dijk L, Mantel-Teeuwisse AK. Pediatric drug formulations: a review of challenges and progress. Pediatrics.
2014;134(2):361-72.
21. Raksamani K. Teaching non - Technical Skills in Anesthesiology. The Thai Journal of Anesthesiology. 2015;41(1):47-52. (In Thai)
22. Grout JR. Mistake proofing: changing designs to reduce error. Qual Saf Health Care. 2006;15(suppl 1):i44-i9.
23. Johnson KB, Butta JK, Donohue PK, Glenn DJ, Holtzman NA. Discharging patients with prescriptions instead of medications: sequelae in a teaching hospital. Pediatrics. 1996;97(4):481-5.
24. Raju TN, Kecskes S, Thornton JP, Perry M, Feldman S. Medication errors in neonatal and paediatric intensive-care units. Lancet. 1989;2:374-6.
25. Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83(6):492-7.
26. Taylor JA, Brownstein D, Christakis DA, Blackburn S, Strandjord TP, Klein EJ, et al. Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics. 2004;114(3):729-35.
27. Stebbing C, Wong ICK, Kaushal R, Jaffe A. The role of communication in paediatric drug safety. Arch Dis Child. 2007;92(5):440-5.
28. Kahn S, Abramson EL. What is new in paediatric medication safety? Arch Dis Child. 2019;104(6):596-9.
29. Mullett CJ, Evans RS, Christenson JC, Dean JM. Development and impact of a computerized pediatric antiinfective decision support program. Pediatrics. 2001;108(4):E75.
30. Lehmann CU, Conner KG, Cox JM. Preventing provider errors: online total parenteral nutrition calculator. Pediatrics. 2004;113(4):748-53.
31. Potts AL, Barr FE, Gregory DF, Wright L, Patel NR. Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics. 2004;113(1):59-63.
32. King WJ, Paice N, Rangrej J, Forestell GJ, Swartz R. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;112(3):506-9.
33. Sethuraman U, Kannikeswaran N, Murray KP, Zidan MA, Chamberlain JM. Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department. Acad Emerg Med. 2015;22(6):714-9.
34. Walsh KE, Kaushal R, Chessare JB. How to avoid paediatric medication errors: a user's guide to the literature. Arch Dis Child. 2005;90(7):698-702.
35. Zorc JJ, Hoffman JM, Harper MB. IT in the ED: a new section of pediatric emergency care. Pediatr Emerg Care. 2012;28(12):1399-401.
36. Chaparro JD, Classen DC, Danforth M, Stockwell DC, Longhurst CA. National trends in safety performance of electronic health record systems in children’s hospitals. J Am Med Inform Assoc. 2017;24(2):268-74.
37. Stucky ER; American Academy of Pediatrics Committee on Drugs; Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 2003;112(2):431-6.
38. Conroy S, North C, Fox T, Haines L, Planner C, Erskine P, et al. Educational interventions to reduce prescribing errors. Arch Dis Child. 2008;93(4):313-5.
39. Siebert JN, Ehrler F, Combescure C, Lacroix L, Haddad K, Sanchez O, et al. A mobile device app to reduce time to drug delivery and medication errors during simulated pediatric cardiopulmonary resuscitation: a randomized controlled trial. J Med Internet Res. 2017;19(2):e31.
40. Miller MR, Takata G, Stucky ER, Neuspiel DR; American Academy of Pediatrics Steering Committee on Quality Improvement and Management; Committee on Hospital Care. Principles of pediatric patient safety: reducing harm due to medical care. Pediatrics. 2011;127(6):1199-210.
41. Fortescue EB, Kaushal R, Landrigan CP, McKenna KJ, Clapp MD, Federico F, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;111(4):722-9.
42. Rosenfeld E, Kinney S, Weiner C, Newall F, Williams A, Cranswick N, et al. Interdisciplinary medication decision making by pharmacists in pediatric hospital settings: an ethnographic study. Res Social Adm Pharm. 2018;14:269-78.
43. Nunn AJ. Making medicines that children can take. Arch Dis Child. 2003;88(5):369-71.
44. Roark DC. Bar codes and drug administration: can new technology reduce the number of medication errors? Am J Nurs. 2004;104(1):63-6.
45. American Society of Health-System Pharmacists. ASHP guidelines on the safe use of automated dispensing devices. Am J Health Syst Pharm. 2010;67:483-90.
46. Schwarz HO, Brodowy BA. Implementation and evaluation of an automated dispensing system. Am J Health Syst Pharm. 1995;52:823-8.
47. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication accurately. Pediatrics. 1997;100(3):330-3.
48. Wong ICK, Basra N, Yeung VW, Cope J. Supply problems of unlicensed and off-label medicines after discharge. Arch Dis Child. 2006;91(8):686-8.
ดาวน์โหลด
เผยแพร่แล้ว
2019-09-24
รูปแบบการอ้างอิง
Pothisuntorn, P. (2019). ความคลาดเคลื่อนทางยาในเด็กและแนวทางการป้องกัน. ไทยไภษัชยนิพนธ์, 14(2), 105–118. https://doi.org/10.69598/tbps.14.2.105-118
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