醫(yī)院可以降低高警訊藥物對病患的傷害

醫(yī)院降低高警訊藥物對病患傷害的建議策略，發(fā)表于九月照護(hù)安全與品質(zhì)聯(lián)合委員會期刊（Joint Commission Journal on Quality and Healthcare Safety）的一篇報告中，本期刊中還有一篇案例研究，描述Fairview健康服務(wù)中心降低嚴(yán)重鎮(zhèn)靜劑過度鎮(zhèn)靜比率的努力。

健康照護(hù)改善中心的Frank Federico博士指出，健康照護(hù)改善中心(IHI)的12介入中心，在其5百萬救命活動(此活動設(shè)定的目標(biāo)是在2006年12月到2008年12月減少5百萬件意外)中提出建議：預(yù)防高警訊藥物。

從抗凝血藥、鎮(zhèn)靜劑、止痛藥和胰島素開始，藥物是住院病患健康照護(hù)最常使用的治療方式，也是最常發(fā)生不良反應(yīng)的；根據(jù)藥物研究中心(IOM)的報告－預(yù)防藥物疏失，在美國每年發(fā)生150萬件可預(yù)防的不良藥物事件(ADEs)，而住院病患每年發(fā)生40萬 件不良藥物事件而導(dǎo)致35億美金的額外損失。

改善抗凝血劑的特殊安全建議如下：

* 制定抗凝血劑藥物安全單張與規(guī)范，要求病患出院到照護(hù)機構(gòu)或返家時遵守。

* 對住院和門診病患提供抗凝血劑量服務(wù)或者診間諮詢。

* 檢查數(shù)據(jù)必須提供給對此數(shù)據(jù)能有所因應(yīng)的照護(hù)者。

* 允許藥師依照給藥規(guī)范并參考檢查數(shù)據(jù)調(diào)整抗凝血劑劑量。

* warfarin的開始劑量須限制在2.5或5mg，依照病患的年紀(jì)和/或共病癥而定。

* 必須對藥物處方進(jìn)行藥物交互作用確認(rèn)。

改善肝素(heparin)的特殊安全建議如下：

* 建立和遵守標(biāo)準(zhǔn)給藥劑量規(guī)范。

* 如果發(fā)生肝素過量而過度抗凝血時，須有停用肝素或逆轉(zhuǎn)治療的規(guī)范。

* 將可用濃度降到最低，以簡化和降低潛在風(fēng)險。

改善warfarin的特殊安全建議如下：

* 開始和維持warfarin治療須有標(biāo)準(zhǔn)規(guī)范，這些包括維他命k劑量規(guī)范。

* 需發(fā)展有實證基礎(chǔ)的手術(shù)間續(xù)用或停用warfarin的規(guī)范。

* 檢查數(shù)據(jù)須在兩個小時內(nèi)提供給照護(hù)單位，或者直接在病床邊監(jiān)測。

* 國際標(biāo)準(zhǔn)化比率(INR)結(jié)果和劑量改變的關(guān)系必須紀(jì)錄在推移圖(The Run Chart)或者管制圖(control chart)。

* 病患和家屬必須參加自我管理。

改善止痛藥/鴉片類的特殊安全建議如下：

* 開始和維持疼痛管理的規(guī)范需標(biāo)準(zhǔn)化。

* 需要適當(dāng)監(jiān)測以偵測止痛藥和鴉片類藥物的副作用。

* 須有解毒劑和使用規(guī)范，以便在無醫(yī)囑下仍可進(jìn)行。

* 如果照護(hù)醫(yī)師沒有疼痛控制經(jīng)驗，需諮詢疼痛專家；依照臨床經(jīng)驗，這些專家包括護(hù)士、藥師、外科醫(yī)師或者其他有經(jīng)驗者。

* 需盡可能采取非藥理介入處置疼痛和焦慮。

* 止痛幫浦需設(shè)定程式并由藥局或護(hù)士進(jìn)行二度確認(rèn)。

* 病患自控止痛藥以及硬腦(脊)膜外止痛藥必須在護(hù)理站內(nèi)二度確認(rèn)。

* 如果可以，盡量減少或不用多種止痛藥物。

改善胰島素的特殊安全建議如下：

* 開始使用任何靜脈胰島素之前，藥物種類、濃度、劑量、幫浦設(shè)定、給藥途徑、病患本身因素都必須再次確認(rèn)。

* 事先規(guī)定好的糖尿病與胰島素輸注表單。

* 外觀相似和藥名相似的藥物必須以不同標(biāo)示分開，給藥時間也應(yīng)區(qū)隔，儲放距離也須分開。

* 所有的輸液必須在藥局內(nèi)準(zhǔn)備，并且以單一濃度提供。

* 病患應(yīng)可以自我管理其胰島素。

* 需調(diào)節(jié)用餐和使用胰島素的時間。

改善鎮(zhèn)靜劑的特殊安全建議如下：

* 儲存和處方的口服中效鎮(zhèn)靜劑應(yīng)該只有濃度。

* 使用事先印好的醫(yī)囑形式處方麻醉型止痛藥和鎮(zhèn)靜劑。

* 使用chloral hydrate進(jìn)行術(shù)前鎮(zhèn)靜的所有小孩，必須在手術(shù)前中后加以監(jiān)控。

* 在病患鎮(zhèn)靜進(jìn)行手術(shù)的過程中，一如其他服用鎮(zhèn)靜劑的狀況，需備妥適合病患年紀(jì)與體型的復(fù)蘇設(shè)備和相關(guān)藥劑。

Federico醫(yī)師指出，5百萬救命活動聚焦在高警訊藥物，是降低藥物引起傷害之整體策略的一部分，此活動的目標(biāo)是降低50%的高警訊藥物相關(guān)傷害，組織一些安全策略，如重新設(shè)計給藥途徑、讓病患參與、建立安全文化、減少責(zé)怪與加強溝通、對高風(fēng)險藥物的使用加以標(biāo)準(zhǔn)化和簡單化之后，ADEs 可以顯著減少。

來自Fairview健康服務(wù)中心的Steven Meisel及其同事所進(jìn)行的案例研究中，描述了麻醉型止痛藥物過度鎮(zhèn)靜案例的減少情況，他們是透過整合7家醫(yī)院、30家一線照護(hù)診所、31間零售藥局、居家照護(hù)和安寧機構(gòu)和其他許多計劃。

作者指出，1999年12月時，F(xiàn)airview Southdale醫(yī)院發(fā)生令人震驚的事件，健康病患因為麻醉型止痛藥過量而呼吸衰竭致死案例，此案例特別麻煩，因為給藥劑量屬常規(guī)且合乎慣例，沒有明顯的藥物疏失，且當(dāng)時的病患監(jiān)測數(shù)據(jù)都在安全標(biāo)準(zhǔn)內(nèi)；為了確定此案例是單一個案或是一種類型的一部分，因而回顧了兩個月以內(nèi)的所有使用naloxone案例。

結(jié)果發(fā)現(xiàn)有11件嚴(yán)重過度鎮(zhèn)靜案例，刺激醫(yī)界評估及校正麻醉型止痛劑過度鎮(zhèn)靜的相關(guān)因子。

Fairview Southdale醫(yī)院在2000年4月組織了一個包含護(hù)士、藥師、麻醉技師、家庭醫(yī)師、呼吸治療師、麻醉醫(yī)師以及品管人員的委員會，希望降低嚴(yán)重麻醉型止痛劑過度鎮(zhèn)靜達(dá)75%。

嚴(yán)重(第3和第4類)事件每月追蹤，每年計算比率，在追蹤到第12個月時，該團隊檢測和執(zhí)行34項改變，包括病患評估和監(jiān)測、個人化麻醉劑治療、以及跨科與跨部門溝通。

在2001年中時，達(dá)到降低嚴(yán)重不良反應(yīng)達(dá)75%的目標(biāo)。

作者結(jié)論表示，F(xiàn)airview 疼痛委員會持續(xù)進(jìn)行可以改善的機會，嚴(yán)重度分類系統(tǒng)轉(zhuǎn)到“國際藥物錯誤報告及預(yù)防委員會(NCC MERP)”系統(tǒng)，有助于我們確認(rèn)額外的改善機會；從手術(shù)步驟如內(nèi)視鏡手術(shù)、二氧化碳濃度監(jiān)測儀(Capnography)使用規(guī)范開始發(fā)展，新的病患控制麻醉藥物和硬腦(脊)膜外幫浦需內(nèi)建安全的特征、醫(yī)囑設(shè)定須不斷地再確認(rèn)。

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.