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Minder toedienfouten met medicatie, wat helpt echt?

  • KLINISCHE LES
  • Published:
Nederlands Tijdschrift voor Evidence Based Practice

Abstract

Uit het rapport ‘Onbedoelde schade’ blijkt dat naar schatting elk jaar 1.735 patiënten in Nederlandse ziekenhuizen overlijden ten gevolge van onbedoelde schade.1) Medicatiefouten blijken een belangrijke oorzaak van onbedoelde schade te zijn en kunnen optreden in verschillende fasen van het medicatieproces. Verpleegkundigen zijn vooral betrokken bij het laatste deel van het medicatieproces, het toedienen van de medicatie.2) Uit onderzoek blijkt dat bijna de helft van medicatiefouten toedienfouten zijn. In deze klinische les wordt ingegaan op de omvang, soorten en oorzaken van medicatiefouten. Vervolgens wordt de effectiviteit besproken van een aantal veel toegepaste interventies om het aantal toedienfouten met medicatie te verminderen.

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Literatuur

  1. Wagner C, de Bruijne MC. Onbedoelde schade in Nederlandse ziekenhuizen. 2007.

  2. Wesslink EJ, van Kooten B, Ros JJW. Informatisering draagt bij aan medicatieveiligheid. Pharmaceutisch Weekblad 2005; 140:3.

    Google Scholar 

  3. Barker KN, Flynn EA, Pepper GA. Observation method of detecting medication errors. Am J Health Syst Pharm 2002; 59(23):2314-2316.

    PubMed  Google Scholar 

  4. Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 2002; 59(5):436-446.

    Google Scholar 

  5. Wat is de CMR? 2010. 25-8-2010.

  6. CMR-projectteam. Jaarrapportage Centrale Medicatiefouten Registratie 2008. 2009.

  7. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324(6):377-384.

    Article  PubMed  CAS  Google Scholar 

  8. Krahenbuhl-Melcher A, Schlienger R, Lampert M, Haschke M, Drewe J, Krahenbuhl S. Drug-related problems in hospitals: a review of the recent literature. Drug Saf 2007; 30(5):379-407.

    Article  Google Scholar 

  9. Poon EG, Keohane C, Featherstone E, Hays B, Dervan A, Woolf S, et al. Impact of barcode medication administration technology on how nurses spend their time on clinical care. AMIA Annu Symp Proc 2006;1065.

  10. Reason J. Human error: models and management. BMJ 2000; 320(7237):768-770.

    Article  PubMed  CAS  Google Scholar 

  11. Kohn L.T., Corrigan JM, Donaldson MS. To err is human: building a safer healthcare system. Washington: National Academy Press; 2000.

    Google Scholar 

  12. Davidhizar R, Lonser G. Medication errors: what case managers can do. Part 2. Hosp Case Manag 2002; 10(5):77-80.

    Google Scholar 

  13. Stucky ER. Prevention of medication errors in the pediatric inpatient setting. Pediatrics 2003; 112(2):431-436.

    Article  PubMed  Google Scholar 

  14. Hodgkinson B, Koch S, Nay R. Strategies to reduce medication errors with reference to older adults. Int J Evid Based Healthcare 2006; 4:2-41.

    Article  Google Scholar 

  15. Jones SW. Reducing medication administration errors in nursing practice. Nurs Stand 2009; 23(50):40-46.

    CAS  Google Scholar 

  16. Wilson A. Nurses’ maths: researching a practical approach. Nurs Stand 2003; 17(47):33-36.

    Google Scholar 

  17. Kruse H, Johnson A, O’Connell D, Clarke T. Administering non-restricted medications in hospital: the implications and cost of using two nurses. Aust Clin Rev 1992; 12(2):77-83.

    PubMed  CAS  Google Scholar 

  18. Jarman H, Jacobs E, Zielinski V. Medication study supports registered nurses’ competence for single checking. Int J Nurs Pract 2002; 8(6):330-335.

    Article  PubMed  Google Scholar 

  19. Anderson DJ, Webster CS. A systems approach to the reduction of medication error on the hospital ward. J Adv Nurs 2001; 35(1):34-41.

    Article  PubMed  CAS  Google Scholar 

  20. Greengold NL, Shane R, Schneider P, Flynn E, Elashoff J, Hoying CL, et al. The impact of dedicated medication nurses on the medication administration error rate: a randomized controlled trial. Arch Intern Med 2003; 163(19):2359-2367.

    Article  PubMed  Google Scholar 

  21. Cohen H, Robinson ES, Mandrack M. Getting to the root of medication errors: Survey results. Nursing 2003; 33(9):36-45.

    PubMed  Google Scholar 

  22. Lawton R, Parker D. Procedures and the professional: the case of the British NHS. Soc Sci Med 1999; 48(3):353-361.

    Article  PubMed  CAS  Google Scholar 

  23. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003; 348(25):2526-2534.

    Article  PubMed  Google Scholar 

  24. Bates DW. Using information technology to reduce rates of medication errors in hospitals. BMJ 2000; 320(7237):788-791.

    Article  PubMed  CAS  Google Scholar 

  25. CPOE, bedside technology, and patient safety: a roundtable discussion. Am J Health Syst Pharm 2003; 60(12):1219-1228.

  26. Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998; 280(15):1311-1316.

    Article  PubMed  CAS  Google Scholar 

  27. Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess (Summ) 2001;(43):i-668.

    Google Scholar 

  28. Biron AD, Loiselle CG, Lavoie-Tremblay M. Work interruptions and their contribution to medication administration errors: an evidence review. Worldviews Evid Based Nurs 2009; 6(2):70-86.

    Article  PubMed  Google Scholar 

  29. Armitage G, Knapman H. Adverse events in drug administration: a literature review. J Nurs Manag 2003; 11(2):130-140.

    Article  PubMed  Google Scholar 

  30. Fry MM, Dacey C. Factors contributing to incidents in medicine administration. Part 1. Br J Nurs 2007; 16(9):556-558.

    Google Scholar 

  31. Relihan E, O’Brien V, O’Hara S, Silke B. The impact of a set of interventions to reduce interruptions and distractions to nurses during medication administration. Qual Saf Health Care 2010.

  32. Pape TM. Applying airline safety practices to medication administration. Medsurg Nurs 2003; 12(2):77-93.

    PubMed  Google Scholar 

  33. Pape TM, Guerra DM, Muzquiz M, Bryant JB, Ingram M, Schranner B, et al. Innovative approaches to reducing nurses’ distractions during medication administration. J Contin Educ Nurs 2005; 36(3):108-116.

    PubMed  Google Scholar 

  34. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010; 170(8):683-690.

    Google Scholar 

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Authors and Affiliations

  1. www.bsl.nl

    Marian Smeulers

  2. Afdeling Kwaliteit en Proces Innovatie, Hogeschool van Amsterdam, Amsterdam, Netherlands

    Hester Vermeulen

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  1. Marian Smeulers
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  2. Hester Vermeulen
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stafadviseur Kwaliteit en Procesinnovatie AMC

stafadviseur en senior onderzoeker,AMC Amsterdam, docent EBP en lid lectoraat EBN, Amsterdam School of Health Professions,

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Smeulers, M., Vermeulen, H. Minder toedienfouten met medicatie, wat helpt echt?. NED. TIJDS. EVID. PRACT. 8, 4–8 (2010). https://doi.org/10.1007/s12468-010-0039-8

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  • DOI: https://doi.org/10.1007/s12468-010-0039-8

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