Factors Influencing Medication Errors in the Prehospital Paramedic Environment: A Mixed Method Systematic Review

There is limited research available on safe medication management practices in emergency medical services (EMS) practice, with most evidence-based medication safety guidelines based on research in nursing, operating theater and pharmacy settings. Prevention of errors requires recognition of contributing factors across the spectrum from the organizational level to procedural elements and patient characteristics. Evidence is inconsistent regarding the incidence of medication errors and multiple sources also state that errors are under-reported, making the true magnitude of the problem difficult to quantify. Definitions of error also vary, with the specific context of medication errors in prehospital practice yet to be established. The objective of this review is to identify the factors influencing the occurrence of medication errors by EMS personnel in the prehospital environment. The review included both qualitative and quantitative research involving interventions or phenomena related to medication safety or medication error by EMS personnel in the prehospital environment. A search of multiple databases was conducted to identify studies meeting these inclusion criteria. All studies selected were assessed for methodological quality; however, this was not used as a basis for exclusion. Each stage of study selection, appraisal and data extraction was conducted by two independent reviewers, with a third reviewer deciding any unresolved conflicts. The review follows a convergent integrated approach, conducting a single qualitative synthesis of qualitative and “qualitized” quantitative data. Fifty-six articles were included in the review, with case reports and qualitative studies being the most frequent study types. Qualitative analysis revealed seven major themes: organizational factors (with reporting as a sub-theme), equipment/medications, environmental factors, procedure-related factors, communication, patient-related factors (with pediatrics as a sub-theme) and cognitive factors. Both contributing factors and protective factors were identified. The body of evidence regarding medication errors is heterogenous and limited in both quantity and quality. Multiple factors influence medication error occurrence; knowledge of these is necessary to mitigate the risk of errors. Medication error incidence is difficult to quantify due to inconsistent measure, definitions and contexts of research conducted to date. Further research is required to quantify the prevalence of identified factors in specific practice settings.

目前针对急诊医疗服务（Emergency Medical Services，EMS）场景下的安全用药管理实践的研究较为匮乏，多数循证用药安全指南均基于护理、手术室及药房场景的研究成果制定。要防范用药差错，需识别从组织层面、流程环节到患者特征等全链条的相关影响因素。现有关于用药差错发生率的研究结论并不一致，且多项研究均指出用药差错存在漏报情况，导致该问题的真实严重程度难以量化。用药差错的定义也尚未统一，院前场景下用药差错的特定界定仍有待明确。本综述的研究目标为识别院前环境中急诊医疗服务人员发生用药差错的影响因素。本综述纳入了所有与院前场景下急诊医疗服务人员用药安全或用药差错相关的干预类或现象类定性与定量研究。研究团队通过检索多个数据库以筛选符合上述纳入标准的文献。所有纳入的研究均接受了方法学质量评价，但该评价未作为文献排除的依据。文献筛选、质量评价及数据提取的所有环节均由两名独立评审人员完成，若出现分歧则由第三名评审人员进行裁决。本综述采用整合汇聚研究方法，对定性数据以及经质性转化的定量数据开展统一的质性综合分析。本综述最终纳入56篇文献，其中个案报告与定性研究为占比最高的文献类型。质性分析结果共提炼出7大类核心主题：组织相关因素（含漏报作为子主题）、设备/药品相关因素、环境相关因素、流程相关因素、沟通相关因素、患者相关因素（含儿科作为子主题）以及认知相关因素。研究同时识别出了用药差错的风险因素与保护因素。现有关于用药差错的研究证据异质性较强，且在数量与质量上均存在局限。多种因素均可影响用药差错的发生，明确这些因素是降低差错风险的必要前提。由于现有研究在测量方式、定义及场景上均存在不一致，用药差错的发生率难以准确量化。未来仍需开展进一步研究，以明确已识别的各类影响因素在特定实践场景中的流行程度。