【正文】 男性發(fā)熱患者，處方普魯卡因青霉素肌注。因未分別包裝，以致貼錯標(biāo) 箋 ，致人死亡。但當(dāng)班醫(yī)師未行解救措施，致次日病情惡化、休克死亡。母親嘗才知藥錯。取藥后，母以奶瓶沖藥喂服，嬰啼，拒服。 — 反映單位麻醉藥品管理混亂， 藥劑人員工作馬虎， 缺少必要的核查制度。 骨折患者、嗎啡注射止痛。 此類事故臨床常有發(fā)生，應(yīng)予高度警惕。 藥師將氨酰膽堿視作氨甲酰膽堿， 致呼吸衰竭死亡。 30 藥物治療錯誤導(dǎo)致醫(yī)療事故實(shí)例（ 3） ?誤將 氨酰膽堿 （去極化類肌松藥）當(dāng)作 氨甲酰膽堿 （擬 M膽堿藥）使用致患者死亡。 29 藥物治療錯誤導(dǎo)致醫(yī)療事故實(shí)例（ 2） ?超極量氨茶堿 靜脈注射，致呼吸困難患者死亡（ %氨茶堿 2ml 2 1支 ） ?誤將“ 信石 ”（三氧化二砷）當(dāng)作“ 寒水石 “發(fā)出， 致病兒死亡。 ?誤將 氯化鉀 注射當(dāng)作 碳酸氫鈉 注射液， 致腸炎脫水病兒高血鉀癥死亡。 28 藥物治療錯誤導(dǎo)致醫(yī)療事故實(shí)例 ? An elderly patient with rheumatoid arthritis died after receiving an overdose of methotrexate (甲氨喋呤 ) a 10 mg daily dose of the drug rather than the intended 10 mg weekly dose. ? Some dosing mixups have occurred because daily dosing of methotrexate is typically used to treat people with cancer, while low weekly doses of the drug have been prescribed for other conditions, such as arthritis, asthma, and inflammatory bowel disease. 29 劑量與用法錯誤 藥物治療錯誤導(dǎo)致醫(yī)療事故實(shí)例 ? One patient died because 20 units of insulin (胰島素 )was abbreviated as 20 U, but the U was mistaken for a zero. As a result, a dose of 200 units of insulin was accidentally injected. 29 劑量與用法錯誤 藥物治療錯誤導(dǎo)致醫(yī)療事故實(shí)例 ? A man died after his wife mistakenly applied six transdermal patches to his skin at one time. ?The multiple patches delivered an overdose of the narcotic pain medicine fentanyl (芬太尼 ) through his skin. 29 劑量與用法錯誤 藥物治療錯誤導(dǎo)致醫(yī)療事故實(shí)例 ? A patient developed a fatal hemorrhage when given another patient39。 用法說明不清導(dǎo)致患者不能理解（藥師有責(zé)） 。 26 藥物治療錯誤的表現(xiàn)（ 2） ? 藥品使用方法錯誤（護(hù)士責(zé)任） 未按預(yù)定時間用藥（漏服） 未按預(yù)定的間隔時間用藥 未按預(yù)定的方法用藥 （ 靜注速度過快、肌注藥誤作靜注） ? 用藥監(jiān)測錯誤（醫(yī)師、藥師責(zé)任） 腎毒性藥物使用前后未作腎功能檢測； 慢性病患者加用藥物時，未作藥歷復(fù)習(xí)造成不必要的藥物 相互作用； 治療窗窄小的藥物，未作 TDM 。 ? 致命性的、嚴(yán)重 ADEs中， 42 %是可預(yù)防的 ? 每例可預(yù)防的 ADEs, 導(dǎo)致住院時間延長 ? 受調(diào)研單位因 ADEs導(dǎo)致醫(yī)藥費(fèi)增加達(dá) $ 560萬元 — Bates DW et al: The costs of adverse drug events in hospitalized patients. JAMA 1997 277: 307 24 藥 物 治 療 錯 誤 的 危 害 More Bad News About Medication Errors Dynamic Chiropractic, Sep 14, 2023 by Babcock, Stephane IOM Report: Million Injured or Killed Annually . ? According to the latest estimates from the Institute of Medicine (IOM), ? a staggering million Americans are the victims of medication errors every year, with approximately 400,000 of those errors considered preventable. ? The 2023 IOM estimates are distinctly higher than previous estimates that projected between 380,000 and 800,000 preventable adverse drug events occurring annually. 24 藥 物 治 療 錯 誤 的 危 害 More Bad News About Medication Errors Dynamic Chiropractic, Sep 14, 2023 by Babcock, Stephane 美國醫(yī)學(xué)研究院 (IOM)報(bào)告 : 每年致傷或致死 150萬人 ?美國每年因藥物治療錯誤導(dǎo)致傷害或死亡人數(shù)達(dá) 150萬人 ?藥物治療錯誤中約 40萬屬可預(yù)防事件 ?2023 IOM 估計(jì)可預(yù)防藥物不良事件明顯高于以往 報(bào)導(dǎo)的每年 38萬至 80萬 ADEs 24 藥物治療錯誤的危害 24 More Bad News About Medication Errors Dynamic Chiropractic, Sep 14, 2023 by Babcock, Stephane ?The frequency of medication errors and preventable medication related injuries represents a very serious cause for concern ? The mittee estimates that on average, a hospital patient is subject to at least one medication error per day ... at least one quarter of all medicationrelated injuries are preventable. ? Those errors contribute directly to injury and/or death. 藥物治療錯誤的危害 24 More Bad News About Medication Errors Dynamic Chiropractic, Sep 14, 2023 by Babcock, Stephane ?藥物治療錯誤和可預(yù)防的用藥傷害的 頻發(fā)，是值得高度關(guān)注的問題 ?估計(jì)平均每一住院患者至少每遭遇一次 用藥錯誤， ?藥物所致傷害四分之一是可預(yù)防的 藥物治療錯誤的危害 24 More Bad News About Medication Errors Dynamic Chiropractic, Sep 14, 2023 by Babcock, Stephane ? Costs related to these incidents also have risen, with a conservative estimate of $ billion spent annually, according to the 2023 report. ? A 2023 analysis of billing information for 37 million Medicare patients by HealthGrades, a healthcare quality pany, estimated that 16 types of patient safety errors resulted in an estimated $19 billion in extra costs and nearly 200,000 unnecessary deaths in hospitals across the . between 2023 and 藥物治療錯誤的危害 2