年长者的最大风险来自治疗本身而非治疗错误


  【24drs.com】根据新西兰针对无过失赔偿资料的一篇分析,年长者在初级照护时之安全的最大威胁来自治疗本身,而非治疗错误或疏忽;这些研究结果发表于10月的家庭医学志。
  
  新西兰奥克兰大学一般实务与初级健康照护系的Katharine Ann Wallis博士发现,医疗伤害(34%)是年长者所有治疗伤害的主要原因,其中,罪魁祸首则是抗生素。
  
  2005-2009年、65岁以上者的294例药物伤害索赔案例中,其中150件(51%)是抗生素引起,其次是非类固醇抗发炎药物(9%)、以及血管收缩素转化酶抑制剂(9%)。
  
  65岁以上者的严重伤害或警讯事件原因中,抗生素也是名列前茅,抗生素在此年龄层引起这类伤害的原因占39%,其次是warfarin (14%)和类固醇(7%)。
  
  严重伤害/警讯事件分类定义为「有可能导致」或「已经导致」、「不预期的死亡或重大的永久失能」。
  
  根据该研究,整体而言,大部份的药物伤害是无过失情况下的过敏与特异体质不良反应(1,295例;药物伤害中的91%、整体伤害的34%)。
  
  研究者使用新西兰的资料,因为它的意外保险模式涵盖所有个人伤害的治疗与复健费用,包括治疗引起的情况,无论病情轻重或过失。对研究者而言,在以侵权为基础的司法管辖区中,这是不可得的观点。
  
  不过,美国家庭医师学院理事长候选人Wanda Filer医师表示,作者描绘的情况是比较准确的。
  
  她指出,年长者特别容易受到抗生素的伤害,因为他们通常服用多种药物而容易发生药物交互作用,另外,卫生体系才刚开始全面探讨病患服用的所有药物。
  
  她表示,我们到了最近才有电子化记录了解病患在不同地点的处方信息,我希望这有助于改善我们的事务。HER警报有助于提醒多重用药,但是,微调是必要的,以防止警报疲劳;即便药物可以被调整,患者使用的市售成药则尚未被纳入。
  
  Filer医师表示,她对抗生素引起伤害的盛行率感到惊讶。她本来预期是[非类固醇抗发炎药物],甚至是warfarin与鸦片类止痛剂。
  
  她形容这些是大开眼界的研究结果,而这篇研究强调,虽然我们听到许多有关非必要使用抗生素与全球抗药性的事情,它们实际上的伤害可能更多。
  
  Wallis博士结论指出,为了改善病患安全,除了减少错误之外,医师们必须减少病患暴露于治疗风险的机会。
  
  这篇研究的初级照护包括:一般开业医/家庭医学科诊所;理疗、整脊和整骨室、牙科诊所、社区药局、检验室、放射科和护理之家。研究者未纳入医院治疗、私人专科诊所、产科医疗引起的索赔。
  
  Wallis博士报告指出资料上的一些限制,这些伤害可能被漏报或者选择性报告。举例来说,跌倒、诊断或治疗延迟或疏失、安眠药、利尿剂、降血糖药和口服抗血小板药物引起之伤害等的索赔相对较少。
  
  资料来源:http://www.24drs.com/
  
  Native link:Treatment, Not Error, Is Biggest Risk to Elderly

Treatment, Not Error, Is Biggest Risk to Elderly

By Marcia Frellick
Medscape Medical News

The greatest threat to older patients' safety in primary care is the risk posed by treatment itself, not treatment error or negligence, according to an analysis of no-fault claims data from New Zealand.

These findings were published in the October issue of the Annals of Family Medicine.

Katharine Ann Wallis, MBChB, PhD, MBHL, FRNZCGP, from the Department of General Practice and Primary Health Care at the University of Auckland in New Zealand, found that medication injuries were the main source (34%) of all treatment injuries among the elderly, and that within that category, antibiotics were, by far, the biggest culprit.

Of 294 medication injuries recorded in claims between 2005 and 2009 among patients aged 65 years and older, 150 of them (51%) were caused by antibiotics. Next highest among injury sources were nonsteroidal anti-inflammatory drugs (9%) and angiotensin-converting enzyme inhibitors (9%).

Antibiotics also topped the list for causes of serious or sentinel injuries for patients aged 65 years and older. Antibiotics caused 39% of such injuries in that age group, followed by warfarin (14%) and steroids (7%).

The serious/sentinel category was defined as having "the potential to result in" or "has resulted in" "unanticipated death or major permanent loss of function."

Most medication injuries overall were allergic and idiosyncratic reactions, without a suggestion of error (1295; 91% of medication injuries and 34% of all injuries), according to the study.

Global Implications

The researchers used New Zealand's data because its accident insurance model provides coverage for treatment and rehabilitation costs for all personal injuries, including those caused by treatment, regardless of severity or fault. It is a view unavailable to researchers in tort-based jurisdictions.

However, Wanda Filer, MD, president-elect of the American Academy of Family Physicians, told Medscape Medical News the picture the author paints is "probably quite accurate here."

The elderly are particularly susceptible to antibiotic injury, she noted, because they often are taking multiple medications, leaving them vulnerable to drug–drug interactions. Also, health systems are just starting to get a picture of all the medications patients are taking.

"Only recently have our electronic records been able to get the information about what patients are being prescribed in different sites. I'm hoping that that will begin to help us improve things," she said. She added that EHR alerts can be helpful for notice of multiple medications, but fine-tuning is needed to prevent alert fatigue.

She noted that even when medications can be reconciled, that does not take into account everything a patient is taking over the counter.

Dr Filer said she was most surprised by the clear prevalence of antibiotics in causes of injury.

"I would have anticipated the [nonsteroidal anti-inflammatory drugs,] and even the warfarin and the opiates," she said.

She called the findings "eye-opening" and said the study emphasized that although we hear much about antibiotics' role in being unnecessary and contributing to global resistance, they also have the potential to do substantial harm.

Dr Wallis concludes: "To improve patients' safety, in addition to reducing error, clinicians need to reduce patients' exposure to treatment risk, where appropriate."

For this study, primary care included general practice/family medicine clinics; physiotherapy, chiropractic, and osteopathy rooms; dental clinics; community pharmacies, laboratories, and radiology rooms; and nursing homes. The researchers excluded claims arising from treatment in hospitals, private specialist clinics, and by maternity clinicians.

Dr Wallis reports some limitations of the data and writes there may be underreporting or selective reporting of injuries.

"For example, there are comparatively few claims for falls, delay or failure to diagnose or treat, and drugs well-known to cause harm, such as hypnotic, diuretic, hypoglycemic, and oral antiplatelet drugs," she writes.

Dr Wallis and Dr Filer have disclosed no relevant financial relationships.

Ann Fam Med. 2015;13:472-474.

    
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