医院可以降低高警讯药物对病患的伤害

医院减少高警戒药物对患者危害的建议和策略，

在9月份发表在《质量和卫生保健安全联合委员会杂志》上的一份报告中，也有一个案例研究。

描述美景镇健康服务中心为降低重度镇静剂过度镇静率所做的努力。

医疗保健改进中心的Frank Federico博士指出，医疗保健改进中心(IHI)的12个干预中心，

在其500万次拯救生命运动(该运动的目标是在2006年12月至2008年12月期间减少500万次事故)中，提出了建议：预防高警戒药物。

从抗凝药、镇静剂、止痛药、胰岛素开始，药物是住院患者保健最常用的治疗手段，也是最常见的不良反应。根据药物研究中心(IOM)-预防药物错误的报告，

在美国，每年发生150万起可预防的药物不良事件(ADEs)，每年住院患者发生40万起药物不良事件，造成35亿美元的额外损失。

改进抗凝剂的特殊安全建议如下：

*制定抗凝药物的安全宣传单和说明书，要求患者出院或回家时遵守。

*为住院和门诊患者提供抗凝剂量服务或咨询。

*检查数据必须提供给能够对此数据做出反应的护理人员。

*允许药剂师根据给药规范并参考检查数据调整抗凝剂的剂量。

*根据患者的年龄和/或合并症，华法林的初始剂量应限制在2.5或5mg。

*药物处方必须确认药物相互作用。

改进肝素的特殊安全建议如下：

*建立并遵守标准剂量规范。

*如因肝素过量导致抗凝过度，需停用肝素或逆转治疗。

*尽量减少可用浓度，以简化和降低潜在风险。

改进华法林的特殊安全建议如下：

*开始和维持华法林治疗必须有标准规范，包括维生素K剂量规范。

*有必要制定术中继续或停用华法林的经验标准。

*检查数据必须在两小时内提供给护理单元，或在床边直接监测。

INR结果和剂量变化之间的关系必须记录在运行图或控制图中。

*患者及其家属必须参与自我管理。

改善止痛药/阿片类药物的特殊安全建议如下：

*开始和维持需要标准化的疼痛管理规范。

*需要进行适当的监测，以发现止痛药和阿片类药物的副作用。

*必须有解药和使用规范，这样在没有医嘱的情况下仍然可以进行。

*如果保健医生没有控制疼痛的经验，请咨询疼痛专家；根据临床经验，这些专家包括护士、药剂师、外科医生或其他有经验的人。

*应尽可能采取非药物干预来处理疼痛和焦虑。

*镇痛泵需要由药房或护士进行两次编程和确认。

*病人自控止痛药和硬膜外止痛药必须在护理站确认两次。

*如果可能，尽量减少或不使用各种止痛药。

改善胰岛素的特殊安全建议如下：

*在开始使用任何静脉注射胰岛素之前，必须再次确认药物类型、浓度、剂量、泵设置、给药途径和患者自身因素。

*预先开具糖尿病和胰岛素输注单。

*外观和药品名称相似的药品必须用不同的标签隔开，给药时间和存放距离也要隔开。

*所有输液必须在药房制备，并以单一浓度提供。

*患者应该能够自己管理胰岛素。

*需要调整进食和使用胰岛素的时间。

改进镇静剂的特殊安全建议如下：

*储存的和处方的口服中度镇静剂应该只有浓度。

*使用预先打印的医嘱开具麻醉性止痛药和镇静剂。

*所有使用水合氯醛进行术前镇静的儿童必须在手术前后进行监测。

*在对患者进行镇静手术时，与其他服用镇静剂的情况一样，需要准备适合患者年龄和体型的复苏设备和相关药物。

费德里科博士指出，这500万次拯救生命的活动集中在高度警戒药物上，这是减少药物造成伤害的整体策略的一部分。这项活动的目标是将与高警戒药物相关的伤害降低50%，并组织一些安全策略。

通过重新设计给药途径、患者参与、建立安全文化、减少责备和加强沟通、规范和简化高危药物的使用，可以显著减少ADEs。

在Fairview健康服务中心的史蒂文梅塞和他的同事进行的案例研究中，描述了使用麻醉镇痛药减少过度镇静的情况。

他们通过整合7家医院、30家一线护理诊所、31家零售药店、家庭护理和临终关怀机构以及许多其他项目来实现这一目标。

提交人指出，1999年12月，Fairview Southdale医院发生了一起令人震惊的事件，一名健康的病人因过量服用麻醉止痛药而死于呼吸衰竭。这个病例特别麻烦，因为剂量是常规的，符合常规。

没有明显的药物疏失，且当时的病患监测数据都在安全标准内；为了确定此案例是单一个案或是一种类型的一部分，因而回顾了两个月以内的所有使用naloxone案例。

结果发现有11件严重过度镇静案例，刺激医界评估及校正麻醉型止痛剂过度镇静的相关因子。

Fairview Southdale医院在2000年4月组织了一个包含护士、药师、麻醉技师、家庭医师、呼吸治疗师、麻醉医师以及品管人员的委员会，希望降低严重麻醉型止痛剂过度镇静达75%。

严重(第3和第4类)事件每月追踪，每年计算比率，在追踪到第12个月时，该团队检测和执行34项改变，包括病患评估和监测、个人化麻醉剂治疗、以及跨科与跨部门沟通。

在2001年中时，达到降低严重不良反应达75%的目标。

作者结论表示，Fairview 疼痛委员会持续进行可以改善的机会，严重度分类系统转到“国际药物错误报告及预防委员会(NCC MERP)”系统，

有助于我们确认额外的改善机会；从手术步骤如内视镜手术、二氧化碳浓度监测仪(Capnography)使用规范开始发展，新的病患控制麻醉药物和硬脑(脊)膜外帮浦需内建安全的特征、医嘱设定须不断地再确认。

Hospitals Can Reduce Patient Harm Related to High-Alert Medications By Laurie Barclay,MD

Medscape Medical News

Recommended strategies for hospitals to reduce patient harm related to high-alert medications are presented in a report in the September issue of the Joint Commission Journal on Quality and Healthcare Safety.A case study in the same issue describes the effort made by Fairview Health Services to reduce the rate of serious narcotic oversedation.'One of the12interventions that the Institute for Healthcare Improvement(IHI)recommends for its5Million Lives Campaign — which has set a target of reducing five million incidents of harm from December2006to December2008— is 'Prevent Harm from High-Alert Medications.starting with a focus on anticoagulants,sedatives,narcotics,and insulin,'' writes Frank Federico,RPh,from the Institute for Healthcare Improvement in Cambridge,Massachusetts.'Medications are the most common intervention in health care and are also most commonly associated with adverse events in hospitalized patients.According to the Institute of Medicine(IOM)report,Preventing Medication Errors,1.5million preventable adverse drug events(ADEs)occur each year in the United States,and400,000adverse drug events that occur each year in hospitalized patients result in $3.5billion in additional costs.'Specific recommendations to improve safety with the use of anticoagulants are as follows: Formatted anticoagulation flow sheets and orders should follow the patient through transfers from hospital,to skilled care facility,to home. An anticoagulant dosing service or 'clinic' is needed in both inpatient and outpatient settings. Laboratory results should be reported to a provider who can act on the findings. Pharmacists should be permitted to change doses of antithrombotic agents based on laboratory values by following protocols approved by medical staff. The starting dose of warfarin should be limited to2.5or5mg,depending on patient age and/or comorbidities. Medication orders should be checked for drug interactions.Specific recommendations to improve safety with the use of heparin are as follows: Standardized protocols and dosing should be established and implemented. Guidelines to hold heparin and give reversal treatment of heparin overanticoagulation should be developed. Minimizing the number of available concentrations allows simplification and reduces the potential for errors.Specific recommendations to improve safety with the use of warfarin are as follows: Standardized protocols should be used when starting and maintaining of warfarin therapy.These should include vitamin K dosing guidelines. An evidence-based protocol should be developed to discontinue and restart warfarin perioperatively. Laboratory results should be made available on the unit within2hours or should be monitored at the bedside. International normalized ratio results vs dose changes should be plotted on the run chart or control chart. Patients and families should participate in self-management.Specific recommendations to improve safety with the use of narcotics/opiates are as follows: Protocols to begin and maintain pain management should be standardized. Appropriate monitoring is needed to detect adverse effects of narcotics and opiates. Protocols and reversal agents should be available that can be given without needing additional physician orders. When the managing physicians are not experienced in pain control,a pain specialist should be consulted.Depending on the clinical setting,these may include specially trained nurses,pharmacists,physicians,or others. Nonpharmacologic intervention for pain and anxiety should be maximized. All pumps should be programmed and independently double-checked by pharmacy or nursing staff. Patient-controlled analgesia and epidural narcotics should be independently double-checked on the unit. Whenever possible,multiple drug strengths should be minimized or eliminated.Specific recommendations to improve safety with the use of insulin are as follows: Before administering any intravenous insulin,the drug,concentration,dose,pump settings,route of administration,and patient identity should be independently double-checked. Pretyped forms are recommended for diabetic and insulin infusion orders. Look-alike and sound-alike drugs should be separated by labeling,time,and distance. All infusions should be prepared in the pharmacy and standardized to a single concentration of intravenous infusion insulin. Patients who are able to should manage their own insulin. Meal and insulin times should be coordinated.Specific recommendations to improve safety with the use of sedatives are as follows: Only1concentration of oral agents for moderate sedation should be stocked and prescribed. Preprinted order forms should be used to order narcotics and sedatives. All children who have received chloral hydrate for preoperative sedation should be monitored before,during,and after the procedure. During procedures performed while the patient is sedated,as well as in other situations where sedatives are administered,age-and size-appropriate resuscitation equipment and reversal agents should be available.'The5Million Lives Campaign's focus on high-alert medications is part of an overall strategy to reduce medically induced harm,' Dr.Federico writes.'The campaign's goal is to achieve a50%reduction in harm related to high-alert medications.ADEs can be reduced significantly by implementing recognized safety measures,such as standardizing and simplifying core medication processes in known high-risk areas,redesigning delivery systems using proven human factors principles,partnering with patients,and creating safety cultures that minimize blame and maximize communication.'The accompanying case study,by Steven Meisel,PharmD,from Fairview Health Services in Minneapolis,Minnesota,and colleagues,describes how narcotic oversedation was reduced across an integrated health system composed of7hospitals,30primary care clinics,31retail pharmacies,a home care and hospice agency,and various other programs.'In December1999,Fairview Southdale Hospital was devastated by the death of an otherwise healthy patient from an apparent narcotic-associated respiratory depression,' the authors write.'This case was particularly troublesome because the doses administered were usual and customary,there were no identified medication errors,and patient monitoring was conducted within all standards at that time.To determine if this case was an isolated event or was part of a pattern,all naloxone administration during a two-month period was retrospectively reviewed.'Eleven cases of serious oversedation were identified,which provided the impetus to evaluate and correct the factors associated with narcotic oversedation.Fairview Southdale Hospital commissioned a team of nurses,pharmacists,anesthetists,a house physician,respiratory therapists,anesthesiologists,and quality resource staff in April2000to decrease serious narcotic oversedation by75%.Serious(class3and4)events were tracked monthly,and rates were annualized.During the following12months,the team tested and implemented34changes involving patient assessment and monitoring,individualizing analgesic treatment,and interdisciplinary and interdepartmental communication.The goal of a75%reduction in serious adverse drug events was reached by mid2001.'The Fairview Pain Committee continues to identify opportunities for improvement,' the authors conclude.'The severity coding system has been changed to the National Coordinating Council for Medication Error Reporting and Prevention(NCC MERP)system,which should help us identify additional opportunities for improvement.Work is beginning on oversedation in procedural areas such as endoscopy,guidelines for the use of capnography are being developed,new patient-controlled analgesia and epidural pumps are being purchased that have greater inherent safety features,and order sets are undergoing continual refinement.'Jt Comm J Qual Patient Saf.2007;33:537-542,543-548.