Es el momento de revisar cómo se preparan y administran los medicamentos inyectables en los hospitales europeos

David H. Cousins, María José Otero, Étienne Schmitt

Resumen


Desde hace décadas se conoce que el uso de los medicamentos  nyectables en los hospitales europeos se encuentra asociado a numerosos  errores de medicación, algunos de los cuales provocan daños graves y  muertes prevenibles. Se han publicado investigaciones e informes  nacionales y europeos sobre la mejora de la seguridad del paciente que  recomiendan una mayor utilización de las unidades de preparación  aséptica de los servicios de farmacia y la provisión de los medicamentos  inyectables listos para su administración, recomendaciones que apenas se  han implementado.

En Inglaterra, la experiencia de tratar a los pacientes con infección por  COVID-19 ha puesto de manifiesto otros beneficios que conlleva la ampliación de las unidades de preparación aséptica de los servicios de farmacia. Estos beneficios incluyen ahorrar tiempo de enfermería,  disponer de sistemas con mayor resiliencia y capacidad, reducir la  variabilidad en la práctica, mejorar la satisfacción del personal clínico y del paciente, y facilitar la administración de más medicamentos inyectables a  los pacientes en sus domicilios. También se ha reconocido que se precisan  actuaciones dirigidas a estandarizar las directrices y procedimientos de  utilización de los medicamentos inyectables e implementar el uso de  dispositivos de infusión inteligentes con software de reducción de errores  de dosis, con el fin de minimizar los errores en la administración de estos  medicamentos. 

Los farmacéuticos de hospital tienen un papel clave en el desarrollo de  stas actividades para que los servicios que prestan las farmacias  hospitalarias europeas estén más en consonancia con los que se  proporcionan en Norteamérica.

 


Palabras clave


Errores de medicación/prevención y control; Administración, medicamentos intravenosos; Preparación de medicamentos; Gestión de la seguridad

Texto completo:

PDF (English) PDF

Referencias


American Society of Health-System Pharmacists. Proceedings of a summit on preventing patient harm and death from i.v. medication errors. Am J Health-System Pharm. 2008;65(15):2367-79.

Hicks R, Becker S. An overview of intravenous-related medication administration errors as reported to MEDMARX, a national medication error-reporting program. J Infus Nurs. 2006;29(1):20-7. DOI: 10.1097/00129804-200601000-00005

Institute for Safe Medication Practices. ISMP safe practice guidelines for adult IV push medications. [Internet] 2015 [accessed 01/16/2021]. Available at: https://www.ismp.org/guidelines/iv-push

Hedlund N, Beer I, Hoppe-Tichy T, Trbovich P. Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings. BMJ Open. 2017;7(12):e015912. DOI: 10.1136/bmjopen-2017-015912

Taxis K, Barber N. Ethnographic study of incidence and severity of intravenous drug errors. BMJ. 2003;326(7391):684-8. DOI: 10.1136/bmj.326.7391.68

Taxis K, Barber N. Causes of intravenous medication errors: an ethnographic study. Qual Saf Health Care. 2003;12(5):343-7. DOI: 10.1136/qhc.12.5.343

McDowell SE, Mt-Isa S, Ashby D, Ferner RE. Republished paper: Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis. Postgrad Med J. 2010;86(1022):734-8. DOI: 10.1136/qshc.2008.029785re

Council of Europe Expert Group on Safe Medication Practices. Creation of a better medication safety culture in Europe: Building up safe medication practices. [Internet] Council of Europe. 2006 [accessed 01/16/2021]. Available at: http://optimiz-sih-circ- med.fr/Documents/Council_of_Europe_Medication_Safety_Report_1 9-03-2007.pdf

Hecq JD. Centralized intravenous additive services (CIVAS): the state of the art in 2010. Ann Pharm Fr. 2011;69(1):30-7. DOI: 10.1016/j.pharma.2010.09.002

Bermejo-Vicedo T, Gorgas MQ. COVID-19 pandemic: New challenge for hospital pharmacy services. Farm Hosp. 2020;44(Suppl 1): 53-4. DOI: 10.7399/fh.11511

Alonso-Herreros JM, Berisa-Prado S, Cañete-Ramírez C, Dávila- Pousa C, Flox- Benítez MP, Ladrón de Guevara-García M, et al. Hospital pharmacy compounding against COVID-19 pandemic. Farm Hosp. 2020;44(Supl 1):S49-52. DOI: 10.7399/fh.11492

Wilkinson E. No going back: how the pandemic is changing hospital pharmacy. [Internet] The Pharmaceutical Journal. 2020 [accessed 01/16/2021]. Available at: https://pharmaceutical- journal.com/article/feature/no-going-back-howthe-pandemic-is- changing-hospital-pharmacy

Department of Health and Social Services (England). Transforming NHS Pharmacy Aseptic Services in England. A national report for the Department of Health and Social Care by Lord Carter of Coles. [Internet] Octubre 2020 [accessed 01/16/2021]. Available at: https://www.gov.uk/government/publications/transforming-nhs- pharmacy-aseptic-services-in-england

Wirtz V, Taxis K, Barber ND. An observational study of intravenous medication errors in the United Kingdom and in Germany. Pharm World Sci. 2003;25:104-11.

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

Thomas AN, Taylor RJ. An analysis of patient safety incidents associated with medication reported from critical care units on the North West of England between 2009 and 2012. Anaesthesia. 2014;69(7):735-45. DOI: 10.1111/anae.12670

Rodríguez-González CG, Herranz-Alonso A, Martín-Barbero ML, Durán-García E, Durango-Limárquez MI, Hernández-Sampelayo P, et al. Prevalence of medication administration errors in two medical units with automated prescription and dispensing. J Am Med Inform Assoc. 2012;19(1):72-8. DOI:10.1136/amiajnl-2011-000332

Sutherland A, Canobbio M, Clarke J, Randall M, Skelland T, Weston E. Incidence and prevalence of intravenous medication errors in the UK: a systematic review. Eur J Hosp Pharm. 2020;27(1):3-8. DOI: 10.1136/ejhpharm-2018-001624

Campino A, Arranz C, Unceta M, Rueda M, Sordo B, Pascual P, et al. Medicine preparation errors in ten Spanish neonatal intensive care units. Eur J Pediatr. 2016;175(2):203-10. DOI: 10.1007/s00431-015-2615-4

Larmené-Beld KHM, Frijlink HW, Taxis K. A systematic review and meta-analysis of microbial contamination of parenteral medication prepared in a clinical versus pharmacy environment. Eur J Clin Pharmacol. 2019;75(5):609-17. DOI: 10.1007/s00228-019- 02631-2

Martín Lancharro P, De Castro-Acuña Iglesias N, González- Barcala FJ, Moure González JD. Evidence of exposure to cytostatic drugs in healthcare staff: a review of recent literature. Farm Hosp. 2016;40(6):604-21. DOI: 10.7399/fh.2016.40.6.9103

Sessink PJM, Nyulasi T, Harladsson ELM, Rebic B. Reduction of contamination with antibiotics on surfaces and in environmental air in three European hospitals following implementation of a closed- system drug transfer device. Ann Work Expo Health. 2019;63(4):459-67. DOI: 10.1093/annweh/wxz010

Council of Europe. Resolution CM/Res AP(2011)1 on quality and safety assurance requirements for medicinal products prepared in pharmacies for the special needs of patients. [Internet] 2011 [accessed 01/16/2021]. Available at: https://www.edqm.eu/sites/default/files/medias/fichiers/About_us/A bout_EDQM/History/resolution_cm_res_2016_1_quality_and_safety _assurance_requirements_for_medicinal_products_prepared_in_pha rmacies.pdf

Council of Europe. Resolution CM/Res(2016)2 on good reconstitution practices in health care establishments for medicinal products for parenteral use. [Internet] 2016 [accessed 01/16/2021]. Available at: https://www.edqm.eu/sites/default/files/resolution_cm_res_2016_2 _good_reconstitution_practices_in_health_care_establishments_for_ medicinal_products_for_parenteral_use_.pdf

Council of Europe. Resolution CM/Res(2016)1 on quality and safety assurance requirements for medicinal products prepared in pharmacies for the special needs of patients. [Internet] 2016 [accessed 01/16/2021]. Available at: https://www.edqm.eu/en/Quality-Safety-Standards-Resolutions- 1588.html

Scheepers HPA, Beaney AM, Le Brun PPH, Neerup Handlos V, Schutjens MDB, Walser S, et al. Aseptic preparation of parenteral medicinal products in healthcare establishments in Europe. Eur J Hosp Pharm. 2016;23(1):50-3. DOI: 10.1136/ejhpharm-2015- 000709

National Patient Safety Agency. Patient Safety Alert 20. Safer use of injectable medicine. [Internet] 2007 [accessed 01/16/2021]. Available at: https://www.sps.nhs.uk/wp- content/uploads/2018/02/2007-NRLS-0434-Injectablemedicines-PSA-2007-v1.pdf

VMS. High risk medication: preparation and administration of parenteralia. Utrech, The Netherlands; 2009.

Ministerio de Sanidad, Servicios Sociales e Igualdad. Guía de buenas prácticas de preparación de medicamentos en servicios de farmacia hospitalaria. [Internet] Junio 2014 [accessed 01/16/2021]. Available at: https://www.sefh.es/sefhpdfs/GuiaBPP_JUNIO_2014_VF.pdf

Beaney AM, Le Brun P, Ravera S, Scheepers H. Council of Europe Resolution CM/Res(2016)2: a major contribution to patient safety from reconstituted injectable medicines? Eur J Hosp Pharm. 2020;27(4):216-21. DOI: 10.1136/ejhpharm-2018-001723

Vrignaud S. Resolution CM/Res(2016)2 and Centralised Intra Venous Additive Services (CIVAS): Challenges and opportunities. Pharmaceutical Technology in Hospital Pharmacy. 2017;2(3):137-42. DOI: 10.1515/pthp-2017-0023

Whitlelaw AG. Letter: Accidental injection of potassium. Br Med J. 1974;13;3(5923):115. DOI: 10.1136/bmj.3.5923.115-a

Breckenridge A. Report of the working party on the addition of drugs to intravenous infusion fluids –Breckenridge report- in health services development. [Internet] London: Department of Health and Social Security; 1976 [accessed 01/16/2021]. Available at: https://www.sps.nhs.uk/wp-content/uploads/2019/04/HC769-Health-Services-Development-Additon-of-Drugs-to-IV-Fluids-The- Breckenridge-Report-DH-1976-1.pdf

Hawkins C. Hazard of potassium chloride solution. Br Med J (Clin Res Ed). 1987;294(6563):54. DOI: 10.1136/bmj.294.6563.54-a3

Cousins DH, Upton DR. Medication Errors: Stop these parenteral blunders. Hospital Pharmacy Practice. 1994;4:388-90.

Cousins DH, Upton DR. Medication Error report 32. Lethal drug ampoules still being issued. Pharmacy in Practice. 1995;5:130-2.

Cousins DH, Upton DR. Is it time to make strong potassium chloride a controlled drug? Pharmacy in Practice. 2000;10:187.

National Patient Safety Agency. Rapid Response Report 2. Risk of confusion between non-lipid and lipid formulations of injectable amphotericin. [Internet] 2007 [accessed 01/16/2021]. Available at: https://webarchive.nationalarchives.gov.uk/20171030131207/http:/ /www.nrls.npsa.nhs.uk/resources/type/alerts/? entryid45=59874&p=3

National Patient Safety Agency. Rapid Response Report 13. Safer administration of Insulin. [Internet] Report 13. 2010 [accessed 01/16/2021]. Available at: https://webarchive.nationalarchives.gov.uk/20171030124645/http:/ /www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=74287

NHS Improvement. Patient Safety Alert. Risk of death and severe harm from error with injectable phenytoin. [Internet] 2016 [accessed 01/16/2021]. Available at: https://www.england.nhs.uk/2016/11/risk-death-and-severe-harm- error-injectablephenytoin/

Lyons I, Furniss D, Blandford A, Chumbley G, Iacovides I, Wei L, et al. Errors and discrepancies in the administration of intravenous infusions: a mixed methods multihospital observational study. BMJ Qual Saf. 2018;27(11):892-901. DOI: 10.1136/bmjqs-2017-007476

Manrique-Rodríguez S, Sánchez-Galindo AC, López-Herce J, Calleja-Hernández MA, Martínez-Martínez F, Iglesias-Peinado I, et al. Impact of implementing smart infusion pumps in a pediatric intensive care unit. Am J Health Syst Pharm. 2013;70(21):1897- 906. DOI: 10.2146/ajhp120767

Manrique-Rodríguez S, Sánchez-Galindo AC, de Lorenzo-Pinto A, González-Vives L, López-Herce J, Carrillo-Álvarez A, et al. Implementation of smart pump technology in a paediatric intensive care unit. Health Informatics J. 2015;21(3):209-22. DOI: 10.1177/1460458213518058

Michalek C, Carson SL. Implementing barcode medication administration and smart infusion pumps is just the beginning of the safety journey to prevent administration errors. Farm Hosp. 2020;44(3):114-21. DOI: 10.7399/fh.11410

Institute for Safe Medication Practices. Guidelines for optimizing safe implementation and use of smart infusion pumps. [Internet] 2020 [accessed 01/16/2021]. Available at: https://www.ismp.org/guidelines/safe-implementation-and-sesmart-pumps

Healthcare Safety Investigation Branch. Investigation into the procurement, usability and adoption of ‘smart’ infusion pumps. [Internet] 2020 [accessed 01/16/2021]. Available at: https://www.hsib.org.uk/investigations-cases/smart-pumps/finalreport/

Clark C. How to implement ‘smart’ pump technology successfully to help reduce IV medication errors. [Internet] Hospital Pharmacy Europe. 2013 [accessed 01/16/2021];68:17-20. Available at: https://hospitalpharmacyeurope.com/wpcontent/uploads/2019/07/C F_RT_2.pdf

Shah N, Jani Y. Implementation of smart infusion pumps: A scoping review and case study discussion of the evidence of the role of the pharmacist. Pharmacy (Basel). 2020;8(4):239. DOI: 10.3390/pharmacy8040239

Vermes A. Centralisation of production and compounding: The Dutch perspective. [Internet] Session PC2: Hospital Mergers and the Centralisation of Production Services, EAHP Annual meeting March 2018 [accessed 01/16/2021]. Available at: https://events.eahp.eu/pdfs/23ac/031.pdf




DOI: http://dx.doi.org/10.7399%2Ffh.11686

Enlaces refback

  • No hay ningún enlace refback.


Incluida en:

Bibliovigilance Dialnet DOAJ Dulcinea EBSCO Embase ESCI Ibecs Latindex MEDES mEDRA MIAR PUBMED REDALYC Redib SciELO SCOPUS Sherpa/Romero

Farmacia Hospitalaria

Sociedad Española de Farmacia Hospitalaria. C/ Serrano n. 40 2º Dcha. - 28001 Madrid

eISSN: 2171-8695 

ISSN-L: 1130-6343

Dep. Legal: M-39835-2012

Correo electrónico de contacto: [email protected]

Los artículos publicados en esta revista se distribuyen con la licencia: Creative Commons Attribution 4.0.

La revista Farmacia Hospitalaria no cobra tasas por el envío de trabajos, ni tampoco cuotas por la publicación de sus artículos.