年長者的最大風險來自治療本身而非治療錯誤


  【24drs.com】根據紐西蘭針對無過失賠償資料的一篇分析,年長者在初級照護時之安全的最大威脅來自治療本身,而非治療錯誤或疏忽;這些研究結果發表於10月的家庭醫學誌。
  
  紐西蘭奧克蘭大學一般實務與初級健康照護系的Katharine Ann Wallis博士發現,醫療傷害(34%)是年長者所有治療傷害的主要原因,其中,罪魁禍首則是抗生素。
  
  2005-2009年、65歲以上者的294例藥物傷害索賠案例中,其中150件(51%)是抗生素引起,其次是非類固醇抗發炎藥物(9%)、以及血管收縮素轉化酶抑制劑(9%)。
  
  65歲以上者的嚴重傷害或警訊事件原因中,抗生素也是名列前茅,抗生素在此年齡層引起這類傷害的原因佔39%,其次是warfarin (14%)和類固醇(7%)。
  
  嚴重傷害/警訊事件分類定義為「有可能導致」或「已經導致」、「不預期的死亡或重大的永久失能」。
  
  根據該研究,整體而言,大部份的藥物傷害是無過失情況下的過敏與特異體質不良反應(1,295例;藥物傷害中的91%、整體傷害的34%)。
  
  研究者使用紐西蘭的資料,因為它的意外保險模式涵蓋所有個人傷害的治療與復健費用,包括治療引起的情況,無論病情輕重或過失。對研究者而言,在以侵權為基礎的司法管轄區中,這是不可得的觀點。
  
  不過,美國家庭醫師學院理事長候選人Wanda Filer醫師表示,作者描繪的情況是比較準確的。
  
  她指出,年長者特別容易受到抗生素的傷害,因為他們通常服用多種藥物而容易發生藥物交互作用,另外,衛生體系才剛開始全面探討病患服用的所有藥物。
  
  她表示,我們到了最近才有電子化記錄瞭解病患在不同地點的處方資訊,我希望這有助於改善我們的事務。HER警報有助於提醒多重用藥,但是,微調是必要的,以防止警報疲勞;即便藥物可以被調整,患者使用的市售成藥則尚未被納入。
  
  Filer醫師表示,她對抗生素引起傷害的盛行率感到驚訝。她本來預期是[非類固醇抗發炎藥物],甚至是warfarin與鴉片類止痛劑。
  
  她形容這些是大開眼界的研究結果,而這篇研究強調,雖然我們聽到許多有關非必要使用抗生素與全球抗藥性的事情,它們實際上的傷害可能更多。
  
  Wallis博士結論指出,為了改善病患安全,除了減少錯誤之外,醫師們必須減少病患暴露於治療風險的機會。
  
  這篇研究的初級照護包括:一般開業醫/家庭醫學科診所;理療、整脊和整骨室、牙科診所、社區藥局、檢驗室、放射科和護理之家。研究者未納入醫院治療、私人專科診所、產科醫療引起的索賠。
  
  Wallis博士報告指出資料上的一些限制,這些傷害可能被漏報或者選擇性報告。舉例來說,跌倒、診斷或治療延遲或疏失、安眠藥、利尿劑、降血糖藥和口服抗血小板藥物引起之傷害等的索賠相對較少。
  
  資料來源: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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