Bir tıbbi onkoloji kliniğindeki parenteral ilaç uygulama hatalarının incelenmesi

Yıl 2022, Cilt: 15 Sayı: 4, 720 - 727, 01.10.2022

Metin Deniz Karakoç , Özden Özer

https://doi.org/10.31362/patd.1088164

Öz

Amaç: Medikal onkolojide hasta sayılarının her geçen yıl artış göstermesi ve kullanılan ilaçların genel olarak pahalı ilaçlar olması nedeniyle parenteral ilaç uygulama hataları (PİUH) birçok tıbbi ve maddi kayıplara neden olmaktadır. Araştırmanın amacı, bir onkoloji kliniğinde meydana gelen PİUH’nı tespit ederek önlenmesi için gerekli tedbirlerin alınmasına katkıda bulunmaktır.
Gereç ve yöntem: Daha önce kanser tanısı konulmuş, tıbbi onkoloji servisinde tedavi gören 2021 yılına ait tüm yatan hastaların dosyaları retrospektif olarak incelendi. Verilerin toplanmasında hemşire gözlem ve takip formları, ramak kala olay bildirim formları, doktor orderları ve hasta bazlı kemoterapi hazırlama birimi raporlarından yararlanıldı. Değişkenlerin incelenmesinde frekans, ortalama ve yüzde (%) gibi tanımlayıcı istatistikler ile ki-kare testi kullanılmıştır.
Bulgular: Çalışma grubunda dosyaları eksiksiz olan 18 yaş üstü 301 hasta olduğu ve 57 adet PİUH yapıldığı belirlenmiştir. Klinikte PİUH oranının %18,9 olduğu hesaplanmıştır. En sık karşılaşılan hataların sırası ile infüzyon sürelerine uyulmaması (%4,6), ilacın yanlış zamanda verilmesi (%4,3) ve ilaç dozunun atlanması/verilmemesi (%3,7) olduğu belirlenmiştir.
Sonuç: Araştırmada tıbbi onkoloji kliniğinde PİUH’nın azımsanamayacak derecede fazla sayıda meydana geldiği ancak bunların büyük bir bölümünün olay bildirim formlarına yansımadığı belirlenmiştir. Hata oranlarının azaltılması amacıyla kliniklerde görevli sağlık personelinin farmakolojik bilgi eksikliklerinin giderilmesi, farmakovijilans konusunda farkındalığın sağlanması, hasta eğitimlerine daha fazla özen gösterilmesi ve dokümantasyon sisteminin revize edilmesi önemli katkılar sağlayabilir. Hastanelerde PİUH’nın önlenmesi için izlenecek ulusal ya da global çapta stratejilerin belirlenebilmesi amacıyla çok merkezli ve büyük ölçekli çalışmalara ihtiyaç bulunmaktadır. 

Anahtar Kelimeler

İlaç uygulama hataları, tıbbi onkoloji, yatan hasta, farmakovijilans, akılcı ilaç kullanımı

Destekleyen Kurum

Çalışma için hiçbir şahıs, şirket ya da kuruluştan herhangi bir maddi destek alınmamıştır.

Proje Numarası

-

Teşekkür

-

Investigation of parenteral drug administration errors in a medical oncology clinic

Öz

Purpose: Parenteral drug administration errors (PDAEs) cause many medical and financial losses, due to the number of patients in medical oncology increases every year and the drugs administered are generally overpriced. The aim of the study is to detect the PDAEs that occur in an oncology clinic and contribute to taking the necessary measures for prevention.
Materials and methods: The all inpatient files who were previously diagnosed with cancer and treated in the medical oncology clinic in 2021 were reviewed retrospectively. Nurse observation and follow-up forms, near-miss event notification forms, physician orders and patient-based chemotherapy preparation unit reports were used to collect data. Descriptive statistics such as frequency, mean and percentage (%), and also chi-square test were used to analyze the variables.
Results: There were 301 patients over the age of 18 with complete files in the study group and 57 PDAEs were detected. It was calculated that the rate of PDAEs in the clinic was 18.9%. It was determined that the most common errors were “not following the administration duration (4.6%)”, “administering the drug at the wrong time (4.3%)”, and “skipping/not administering the drug dose (%3.7)” respectively.
Conclusion: In the study, it was determined a significant number of PDAEs occurred in the medical oncology clinic, but most were not written on the event reporting forms. In order to reduce the error rates, eliminating the pharmacological knowledge deficiencies of the health staff in the clinics, raising awareness about pharmacovigilance, paying more attention about patients’ training and revising the documentation system can make important contributions. Multicenter and large-scale studies are needed to determine the national or global strategies to be followed in order to prevent PDAEs in hospitals.

Anahtar Kelimeler

Drug administration errors, medical oncology, inpatient, pharmacovigilance, rational drug use

Proje Numarası

-

Kaynakça

• Ferlay J, Colombet M, Soerjomataram I, et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries and 25 major cancers in 2018. Eur J Cancer 2018;103:356-387. https://doi.org/10.1016/j.ejca.2018.07.005
• Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021;71:209-249. https://doi.org/10.3322/caac.21660
• Dorothy A, Yadesa TM, Atukunda E. Prevalence of medication errors and the associated factors: a prospective observational study among cancer patients at Mbarara regional referral hospital. Cancer Manag Res 2021;13:3739-3748. https://doi.org/10.2147/CMAR.S307001
• Keers RN, Williams SD, Cooke J, Ashcroft DM. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf 2013;36:1045-1067. https://doi.org/10.1007/s40264-013-0090-2
• Mattsson T, Holm B, Michelsen H, Knudsen J, Brixen K, Herrstedt J. Non-intercepted dose errors in prescribing anti-neoplastic treatment: a prospective, comparative cohort study. Ann Oncol 2015;26:981–986. https://doi.org/10.1093/annonc/mdv032
• Khalil H, Bell B, Chambers H, Şeyh A, Avery AJ. Professional, structural and organisational interventions in primary care for reducing medication errors. Cochrane Database Syst Rev 2017; Issue 10. Art. No.: CD003942. https://doi.org/10.1002/14651858.CD003942.pub3
• Baldo P, Fornasier G, Ciolfi L, Sartor I, Francescon S. Pharmacovigilance in oncology. Int J Clin Pharm 2018;40:832-841. https://doi.org/10.1007/s11096-018-0706-9
• Schwendimann R, Blatter C, Dhaini S, Simon M, Ausserhofer D. The occurrence, types, consequences and preventability of in-hospital adverse events - a scoping review. BMC Health Serv Res 2018;18:521. https://doi.org/10.1186/s12913-018-3335-z
• Religioni U, Pakulska T. Rational drug use in hospital settings - areas that can be changed. J Med Econ 2020;23:1205-1208. https://doi.org/10.1080/13696998.2020.1801455
• Crestan D, Trojniak MP, Francescon S, Fornasier G, Baldo P. Pharmacovigilance of anti-cancer medicines: opportunities and challenges. Expert Opin Drug Saf 2020;19:849-860. https://doi.org/10.1080/14740338.2020.1772751
• Watanabe JH, McInnis T, Hirsch JD. Cost of prescription drug-related morbidity and mortality. Ann Pharmacother 2018;52:829-837. https://doi.org/10.1177/1060028018765159
• Weingart SN, Zhang L, Sweeney M, Hassett M. Chemotherapy medication errors. Lancet Oncol 2018;19:e191-e199. https://doi.org/10.1016/S1470-2045(18)30094-9
• Berdot S, Gillaizeau F, Caruba T, Prognon P, Durieux P, Sabatier B. Drug administration errors in hospital inpatients: a systematic review. PLoS One 2013;8(6):e68856. https://doi.org/10.1371/journal.pone.0068856
• Eishy Oskuyi A, Sharifi H, Asghari R. Medication errors in hematology-oncology ward by consultation: The role of the clinical pharmacologist. Caspian J Intern Med 2021;12:53-58. https://doi.org/10.22088/cjim.12.1.53
• Ulaş A, Silay K, Akinci S, et al. Medication errors in chemotherapy preparation and administration: a survey conducted among oncology nurses in Turkey. Asian Pac J Cancer Prev 2015;16:1699-705. https://doi.org/10.7314/apjcp.2015.16.5.1699
• Vural F, Çiftçi S, Vural B. Sık karşılaşılan ilaç uygulama hataları ve İlaç güvenliği. ACU Sağlık Bil Derg 2014:5:271-275.
• Cloete L. Reducing medication errors in nursing practice. Nurs Stand 2015 20;29:50-59. https://doi.org/10.7748/ns.29.20.50.e9507
• Choi I, Lee SM, Flynn L, Kim CM, Lee S, Kim NK, Suh DC. Incidence and treatment costs attributable to medication errors in hospitalized patients. Res Social Adm Pharm 2016;12:428-437. https://doi.org/10.1016/j.sapharm.2015.08.006
• Elliott RA, Camacho E, Jankovic D, Sculpher MJ, Faria R. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf 2021;30:96-105. https://doi.org/10.1136/bmjqs-2019-010206
• Parthasarathi A, Puvvada R, Patel H, Bhandari P, Nagpal S. Evaluation of medication errors in a tertiary care hospital of a low- to middle-income country. Cureus 2021;13:e16769. https://doi.org/10.7759/cureus.16769
• Lavan AH, Gallagher PF, O'Mahony D. Methods to reduce prescribing errors in elderly patients with multimorbidity. Clin Interv Aging 2016;11:857-866. https://doi.org/10.2147/CIA.S80280
• Stergiopoulos S, Brown CA, Felix T, Grampp G, Getz KA. A Survey of Adverse Event Reporting Practices Among US Healthcare Professionals. Drug Saf 2016;39:1117-1127. https://doi.org/10.1007/s40264-016-0455-4
• Hoel RW, Giddings Connolly RM, Takahashi PY. Polypharmacy management in older patients. Mayo Clin Proc 2021;96:242-256. https://doi.org/10.1016/j.mayocp.2020.06.012
• Karakoç MD. Kanser Hastalarında polifarmasi ve ilaç etkileşimleri. ADÜ Sağ Bil Fak Derg 2022;6:31-42 https://doi.org/10.46237/amusbfd.922779
• Rodziewicz TL, Houseman B, Hipskind JE. Medical error reduction and prevention. In: StatPearls [Internet]. Treasure Island: StatPearls Publishing, 2022;30-41.
• Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Reducing medication errors for adults in hospital settings. Cochrane Database Syst Rev 2021;11:CD009985. https://doi.org/10.1002/14651858.CD009985.pub2
• Bubalo J, Warden BA, Wiegel JJ, et al. Does applying technology throughout the medication use process improve patient safety with antineoplastics? J Oncol Pharm Pract 2014;20:445-60. https://doi.org/10.1177/1078155213514469
• Lee TY, Sun GT, Kou LT, Yeh ML. The use of information technology to enhance patient safety and nursing efficiency. Technol Health Care 2017;25:917-928. https://doi.org/10.3233/THC-170848
• Ho J, Burger D. Improving medication safety practice at a community hospital: a focus on bar code medication administration scanning and pain reassessment. BMJ Open Qual 2020;9:e000987. https://doi.org/10.1136/bmjoq-2020-000987