Personalised, predictive and preventive medication process in hospitals—still rather missing: professional opinion survey on medication safety in Czech hospitals (based on professional opinions of recognised Czech health care experts)

EPMA Journal

Zeno Veselik¹ 

[1] ABC Works CZ s. r. o., U Kříže 632/24, Praha 5 - Jinonice, 158 00 Prague, Czech Republic

关键词: ADMS;    Unit-dose Packaging;    CPOE;    ADE;    safety;    Personalised Medication;    Preventive;    Predictive;   

Others  :  800846
DOI  :  10.1186/1878-5085-5-7

 received in 2014-02-26, accepted in 2014-04-14,  发布年份 2014

【 摘 要 】

The survey had the following aims: (1) to rationalise the hypothesis that risks and losses relating to medication process' errors in Czech hospitals are at least comparable with the other developed countries and EU countries especially, (2) to get a valid professional opinion/estimate on the rate of adverse drug events happening in Czech hospitals, (3) to point out that medication errors represent real and serious risks and (4) to induce the hospital management readiness to execute fundamental changes and improvements to medication processes. We read through a lot of studies inquiring into hospitals' medication safety. Then, we selected the studies which brought reliable findings and formulated credible conclusions. Finally, we addressed reputable Czech experts in health care and asked them structured questions whether the studies' findings and conclusions corresponded with our respondents' own experience in the Czech hospital clinical practice and what their own estimates of adverse drug events' consequences were like. Based on the reputable Czech health care expert opinions/estimates, the rate of a false drug administration may exceed 5%, and over 7% of those cause serious health complications to Czech hospital inpatients. Measured by an average length of stay (ALOS), the Czech inpatients, harmed by a false drug administration, stay in hospital for more than 2.6 days longer than necessary. Any positive changes to a currently used, traditional, ways of drug dispensing and administration, along with computerisation, automation, electronic traceability, validation, or verification, must well pay off. Referring to the above results, it seems to be wise to follow the EU priorities in health and health care improvements. Thus, a right usage of the financial means provided by the EC—in terms of its new health programmes for the period 2014–2020 (e.g. Horizon 2020)—has a good chance of a good result in doing the right things right, at the right time and in the right way. All citizens of the EU may benefit using the best practice.

【 授权许可】

   
2014 Veselik; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Golubnitschaja O, Costigliola V, EPMA: General report & recommendations in Predictive, Preventive and Personalised Medicine 2012: white paper of the European Association for predictive, preventive and personalised medicine. EPMA J 2012, 3:14. http:/www.epmajournal.com/content/3/14 webcite BioMed Central Full Text
• [2]Hrib Z, Vychytil P: Short theoretical introduction into the issue of adverse drug events in providing health care. The Cabinet of Public Healthcare, the 3rd Medical Faculty of Charles University in Prague 2010, 7:14-15.
• [3]European Commission: Policy on patient safety. [http://ec.europa.eu/health/patient_safety/policy/index_en.htm webcite]
• [4]Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG: Incidence of adverse events and negligence in hospitalized patients: results of the Harvard medical practice study I. N Engl J Med 1991, 324(6):370-376.
• [5]Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ: Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000, 38(3):261-271.
• [6]Mills DH, Boyden JS, Rubamne DS: Report on the Medical Insurance Study. San Francisco: Sutter; 1977.
• [7]Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD: The quality in Australian health care study. Med J Aust 1995, 163(9):458-471.
• [8]Isolde Altersberger und Eva Blanché-Ganter (Apothekerinnen Klin. Pharm.), Astrid Ilg (Ärztin Kardiologie), Liselotte Keck-Benz (Stationsleitung Nephrologie), Angelika Pohl (Qualitätsmanagement) - (Städtisches Krankenhaus München-Harlaching): Aufbau und Einführung eines Sicherheitsmanagements zur Vermeidung von Medikationsirrtümern. Weimar: ADKA XXX. Wissenschaftlicher Kongress; 2004. 13. bis 16. Mai
• [9]Goldschmidt AJW, Hilbert J: Krankenhausmanagement mit Zukunft: Orientierungswissen und Anregungen von Experten. Frankfurt am Main: Die Deutsche Nationalbibliothek; 2011.
• [10]Atlersberger I: Aufbau und Einfuhrung eines Sicherheitsmanagements zus Vermeidung von Medikationsirrtumern, Pesterausstellung ADKA XXX. Weimar: Wissenschaftlicher Kongress; 2004. [http://books.google.cz/books?id = cu5eNxR9NiQC&pg = PT527&lpg = PT527&dq = Aufbau + und + Einf%C3%BChrung + eines + Sicherheitsmanagements + zur + Vermeidung + von + Medikationsirrt%C3%BCmern&source = bl&ots = C57OkNZ1N6&sig = TgLftyGM6HBrq7uE2ZHG3cL7Z9E&hl = en&sa = X&ei = 598KUbHLGM7MtAbas4CoBw&ved = 0CFUQ6AEwBA webcite]
• [11]Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL: Medication errors observed in 36 health care facilities. Arch Intern Med 2002, 162(16):1897-1903. [http://archinte.jamanetwork.com/article.aspx?articleid = 212740 webcite]
• [12]Rottenkolber D, Hasford J, Stausberg J: Costs of adverse drug events in German hospitals—a microcosting study. 2012. [http://www.valueinhealthjournal.com/article/S1098-3015(12)01621-X/abstract webcite] and/or at http://www.sciencedirect.com webcite published by Elsevier Inc. in 15th edition of Value in Health, a publication of International Society for Pharmacoeconomics and Outcomes Research (ISPOR) - journal homepage: http://www.elsevier.com/locate/jval webcite
• [13]Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Levtzion-Korach O, Moniz T, Rothschild JM, Kachalia AB, Hayes J, Churchill WW, Lipsitz S, Whittemore AD, Bates DW, Gandhi TK: Effect of bar-code technology on the safety of medication administration. N Engl J Med 2010, 362:1698-1707. doi:10.1056/NEJMsa0907115
• [14]Nebeker JR, Hoffman JM, Weir CR, Bennett CL, Hurdle JF: High rates of adverse drug events in a highly computerized hospital. Arch Intern Med 2005, 165:1111-1116. [http://archinte.jamanetwork.com/on 05/21/2013 webcite]
• [15]Frontini R: Redesigning the drug distribution system in hospitals. [http://www.gs1.org/docs/healthcare/news_events/220610/12_EAHP_Frontini.pdf webcite]
• [16]Amann S, Bonnabry P, Verbeke S, Frontini R: Request for a production of single dose-packed drugs, 2012. [http://eahp.eu/sites/default/files/files/Barcode_2012%20pdf.pdf webcite]
• [17]EAHP: Bar coding medicines to the single unit. [http://eahp.eu/practice-and-policy/bar-coding-medicines-to-the-single-unit webcite]
• [18]Leape LL, Lawthers AG, Brennan TA, Johnson WG: Preventing medical injury. QRB Qual Rev Bull 1993, 19(5):144-149.
• [19]Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, Goldmann DA: Medication errors and adverse drug events in pediatric inpatients. JAMA 2001, 285(16):2114-2120. doi:10.1001/jama.285.16.2114
• [20]Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, Small SD, Sweitzer BJ, Leape LL: The costs of adverse drug events in hospitalized patients. JAMA 1997, 277(4):307-311. http://jama.jamanetwork.com/article.aspx?articleid = 413545 webcite
• [21]Schnurrer JU, Frölich JC: Zur Häufigkeit und Vermeidbarkeit von tödlichen unerwünschten Arzneimittelwirkungen. Internist 2003, 44:889-895.
• [22]Ziegelmeier M, Frenger J, Amann S, Oehring U, Grosshans R: Arzneimittelsicherheit beim Stellen fester oraler Arzneimittel, Postervortrag 1998, Volume 19. XXVII. Wissenschaftlicher Kongress des Bundesverbandes Deutscher Krankenhausapotheker. Germany: KHPharm; 1998:336.
• [23]Kaufmann M, Amstutz M, Staender S: Das WEB als ideale plattform für anonymes critical incident reporting. SMI 2002, 49.
• [24]Hoppe-Tichy T, Noe-Schwenn S, Wahlig A: Taxis Katja: Medikationsfehler bei der Applikation parenteraler Arzneimittel. KHPharm 2002, 23:11-17.
• [25]Nightingale PG, Adu D, Richards NT, Peters M: Implementation of rules based computerised bedside prescribing and administration: intervention study. BMJ 2000, 320:750-753.
• [26]Miltenberger D, Ulsenheimer K: Incident reporting für ein produktives Risikomanagement. Das Krankenhaus 2003, 7:539-543.
• [27]Computerbasiertes Anonymes Critical Incident Reporting Ein Beitrag zur Patientensicherheit [http://www.CIRSmedical.org webcite]
• [28]Williams DJP: Medication errors. [http://www.rcpe.ac.uk/journal/issue/journal_37_4/Williams.pdf webcite]
• [29]Boseley S: 40,000 NHS drug errors logged in a year. [http://www.guardian.co.uk/society/2006/aug/11/health.medicineandhealth1 webcite]
• [30]Graban M: Statistics on healthcare quality and patient safety problems – errors & harm. [http://www.leanblog.org/2009/08/statistics-on-healthcare-quality-and/ webcite]
• [31]Alanko K, Nyholm L: Oops! Another medication error. A literature review of contributing factors and methods to prevent medication errors. http://www.doria.fi/bitstream/handle/10024/29617/stadia-1194960145-7.pdf?sequence = 1 webcite
• [32]Lisby M, Nielsen LP, Mainz J: Errors in the medication process: frequency, type, and potential clinical consequences. Int J Qual Health Care 2005, 17(1):15-22. doi:10.1093/intqhc/mzi015. [http://intqhc.oxfordjournals.org/content/17/1/15.full webcite]
• [33]Taxis K, Dean B, Barber N: Hospital drug distribution systems in the UK and Germany—a study of medication errors. Pharm World Sci 1999, 21(1):25-31. [http://www.ncbi.nlm.nih.gov/pubmed/10214665 webcite]
• [34]Taxis K, Barber N: Incidence and severity of intravenous drug errors. Eur J Clin Pharmacol 2004, 59:815-817. doi:10.1007/s00228-003-0689-9. [http://eprints.pharmacy.ac.uk/1912/1/INCIDENCE_AND_SEVERITY.pdf webcite]
• [35]Burke J, Smith LN, Sveinsdóttir H, Willman A: Patient safety in Europe: medication errors and hospital-acquired infection. [http://eprints.gla.ac.uk/4919/1/5.pdf webcite]