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Incidents et accidents médicamenteux en établissement de santé : une analyse descriptive au sein d'un CHU mère-enfant de 2018 à 2022.
Maurin, Charlotte; Atkinson, Suzanne; Hamouche, Linda; Bussières, Jean-François.
  • Maurin C; , candidate au D. Pharm., est assistante de recherche à l'Unité de recherche en pratique pharmaceutique, département de pharmacie, CHU Sainte-Justine, Montréal (Québec).
  • Atkinson S; , B. Pharm., M. Sc., chef-adjointe aux services pharmaceutiques, unité de recherche en pratique pharmaceutique, département de pharmacie, CHU Sainte-Justine, Montréal (Québec).
  • Hamouche L; , B.S.N., M. Sc., conseillère, gestion des risques, direction de la qualité, évaluation, performance et éthique, CHU Sainte-Justine, Montréal (Québec).
  • Bussières JF; , B. Pharm., M. Sc., M.B.A., F.C.S.H.P., F.O.P.Q., responsable, unité de recherche en pratique pharmaceutique, CHU Sainte-Justine; professeur titulaire de clinique, Faculté de pharmacie, Université de Montréal, Montréal (Québec).
Can J Hosp Pharm ; 77(2): e3528, 2024.
Article en Fr | MEDLINE | ID: mdl-38601133
ABSTRACT

Background:

The safety of care provided is based on an analysis of medication incidents and accidents.

Objective:

The primary objective was to describe medication-related incidents and accidents (I&A) within a university-affiliated hospital.

Methods:

This retrospective descriptive study was based on data from a 500-bed mother-child university-affiliated hospital. All I&As declared between April 1, 2018, and March 31, 2022, were considered. The analysis included all medication-related I&As that occurred during an admission or in an outpatient setting. Some variables were recoded manually. Descriptive statistical analyses were performed.

Results:

A total of 23 284 I&As were considered, including 7578 medication-related I&As. Daily averages of 15.9 ± 14.0 I&As and 5.2 ± 0.3 medication-related I&As were reported. There were 22.4 medication-related I&As/1000 inpatient days. The majority of medication-related I&As occurred in surgery (20%, 1530/7578), oncology (19%, 1405/7578), and pediatrics (16%, 1200/7578). Most were associated with incorrect dosing (21%, 1575/7578); infiltration, extravasation, or removed lines (19%, 1405/7578); and omissions (16%, 1205/7578). Physical consequences were reported in 15% (1158/7578) of the medication-related I&As. Conversely, psychological consequences were reported in less than 1% (44/7578) of medication-related I&As.

Conclusions:

This study provides a comprehensive descriptive profile over a 4-year period. Most of the reported I&As did not lead to consequences for patients. The sharing of ratios promotes comparative analysis with other facilities and can contribute to discussions about risk reduction. A culture of reporting events is present within this health care facility.
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