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