Medikationsfehler
Risikoprävention

Seit Anfang der Siebziger Jahre wurden mehr und mehr Studien zur Häufigkeit parenteraler Medikationsfehler veröffentlicht.⁴ Die britische National Patient Safety Agency hat Zahlen zusammengestellt, welche Typen von Medikationsfehlern in welcher anteiligen Häufigkeit vorkommen. Hierzu wurden mehr als 14.000 Berichte über Vorfälle mit injizierbaren Medikamenten in einem Zeitraum von 18 Monaten ausgewertet.^24,25 In mehr als 4.000 Fällen
(28,9 % des Gesamtaufkommens) bestand der häufigste Medikationsfehler in falscher Dosierung, falscher Wirkstärke oder falscher Verabreichungshäufigkeit des verordneten Arzneimittels.

Fehler und Unregelmäßigkeiten bei der Zubereitung intravenös zu verabreichender Arzneimittel können eine Vielzahl von Konsequenzen haben, die harmlos, schwerwiegend oder tödlich sein können.

Ziel ist es, dass alle Mitarbeiter in der Patientenversorgung die Regeln der „9 Richtigen“ umsetzen.^26,27

¹ _{Döring M, Brenner B, Handgretinger R, Hofbeck M, Kerst G. (2014) Inadvertent intravenous administration  of maternal breast milk in a six-week-old infant: a case report and review oft he literature. BMC Res Notes; 7:17}

² _{Manias E, Kinney S, Cranswick N, Williams A, Borrott N. (2014) Interventions to reduce medication errors in pediatric intensive care. Ann Pharmacother; 48(10): 1313-31}

³ _{JCAHO. (2014) Tubing misconnections -  a persistent and potentially deadly occurrence. Joint Commission on Accreditation of Healthcare Organizations, USA. Sentinel Event Alert; 53: 1-3.}

⁴ _{Simmons D, Symes L, Graves K. (2011) Tubing misconnections: normalization of deviance. Nutrition in Clinical Practice; 26(3): 286-293.}

⁵ _{Valentin A, Capuzzo M, Guidet B, Moreno RP, Dolanski L, Bauer P, Metnitz PG; Research Group on Quality Improvement of European Society of Intensive Care Medicine; Sentinel Events Evaluation Study Investigators. (2006) Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care Med; 32(10): 1591-8}

⁶ _{Cohen MR The Institute of Medicine report, preventing medication errors: another good day. Am J Health Syst Pharm. 2007 Jul 15;64(14 Suppl 9):S1-2. DOI: 10.2146/ajhp070189}

⁷ _{Edwards IR1, Aronson JK. (2000) Adverse drug reactions: definitions, diagnosis, and management. Lancet; 356(9237) :1255-9.}

⁸ _{Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al. (1995) Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA; 274(1): 29-34.}

⁹ _{Gurwitz JH, Field TS, Avorn J, McCormick D, Jain S, Eckler M, et al. (2000) Incidence and preventability of adverse drug events in nursing homes. Am J Med; 109(2): 87-94.}

¹⁰ _{Nebeker JR, Barach P, Samore MH. (2004) Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting. Ann Intern Med;140(10):795-801.}

¹¹ _{McDowell S, Mt-Isa S, Ashby D (2010) Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis. Qual Saf Health Care; 19(4): 341-5}

¹² _{Fraind DB, Slagle JM, Tubbesing VA, Hughes SA, Weinger MB (2002) Reengineering intravenous drug and fluid administration processes in the operating room: step one: task analysis of existing processes. Anesthesiology; 97(1): 139-47.}

¹³ _{Fahimi F, Ariapanah P, Faizi M, Shafaghi B, Namdar R, Ardakani MT (2008) Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: an observational study. Aust Crit Care; 21(2): 110-6.}

¹⁴ _{Ferner RE, Langford NJ, Anton C, Hutchings A, Bateman DN, Routledge PA (2001) Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example. Br J Clin Pharmacol; 52(5): 573-7.}

¹⁵ _{Garnerin P, Pellet-Meier B, Chopard P, Perneger T, Bonnabry P (2007) Measuring human-error probabilities in drug preparation: a pilot simulation study. Eur J Clin Pharmacol; 63(8): 769-76}

¹⁶ _{Parshuram CS, To T, Seto W, Trope A, Koren G, Laupacis A (2008) Systematic evaluation of errors occurring during the preparation of intravenous medication. CMAJ; 178(1): 42-8.}

¹⁷ _{Cousins DH, Sabatier B, Begue D, Schmitt C, Hoppe-Tichy T (2005) Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France. Qual Saf Health Care; 14(3): 190-5.}

¹⁸ _{Cohen H, Robins ES, Mandrack M (2003) Getting to the root of medication errors: Survey results. Nursing; 33(9): 36-45.}

¹⁹ _{Wilson RMcL, Harrison BT, Gibberd RW, Hamilton JD (1999) An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Med J Aust; 170(9): 411-5.}

²⁰ _{Shane R. (2009) Current status of administration of medicines. Am J Health Syst Pharm. 2009; 66(5 Suppl 3): S42-8 12} 

²¹ _{Leape LL, Bates DW, Cullen DJ et al. (1995) Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA; 274(1): 35-43.}

²² _{Reason J (1995) Understanding adverse events: human factors. Qual Health Care; 4(2): 80-9.}

²³ _{Dean B, Schaechter M, Vincent C, et al. (2002) Causes of prescribing errors in hospital inpatients: a prospective study. Lancet; 359(9315): 1373-8.}

²⁴_{David H Cousins, David Gerrett, and Bruce Warner A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005–2010) Br J Clin Pharmacol. 2012 Oct; 74(4): 597–604. DOI: 10.1111/j.1365-2125.2011.04166.x}

²⁵ _{Elliott M, Liu Y. (2010) The nine rights of medication administration: an overview. Br J NursMar 11-24;19(5):300-5.}

²⁶ _{Smeulers M, Verweij L, Maaskant JM, de Boer M, Krediet CT, Nieveen van Dijkum EJ, Vermeulen H. (2015) Quality indicators for safe medication preparation and administration: a systematic review. PLoS One. 2015 Apr 17;10(4):e0122695. doi: 10.1371}

²⁷ _{Dean BS, Barner ND, (1999) A validated, reliable method of scoring the severity of medication errors. Am J Hosp Pharm 56 : 57-62}

²⁸ _{“To Error is Human: Building a Safer Health System,” a November 1999 report from the Institute of Medicine [IOM]}